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Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review. Brain Sci 2022; 12:brainsci12121685. [PMID: 36552145 PMCID: PMC9776068 DOI: 10.3390/brainsci12121685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
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 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.
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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Sharma A, Rieth GE, Tanenbaum JE, Williams JS, Ota N, Chakravarthi S, Manjila S, Kassam A, Yapicilar B. A morphometric survey of the parasellar region in more than 2700 skulls: emphasis on the middle clinoid process variants and implications in endoscopic and microsurgical approaches. J Neurosurg 2018; 129:60-70. [DOI: 10.3171/2017.2.jns162114] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe middle clinoid process (MCP) is a bony projection that extends from the sphenoid bone near the lateral margin of the sella turcica. The varied prevalence and morphological features of the MCP in populations stratified by age, race, and sex are unknown; however, the knowledge of its anatomy and preoperative recognition on CT scans can aid greatly in complication avoidance and management. The aim of this study was to further illustrate the surgical anatomy of the parasellar region and to quantify the incidence of MCP and caroticoclinoid rings (CCRs) in dried preserved human anatomical specimens.METHODSThe presence, dimensions, morphological classification (incomplete, contact, and CCR), and intracranial relations of the MCP were measured in 2726 dried skull specimens at the Hamann-Todd Osteological Collection at the Cleveland Museum of Natural History. Specific morphometric data points were recorded from each of these hemiskulls, and categorized based on age, sex, and ethnicity. Linear and logistic regressions were used to determine associations between explanatory variables and MCP morphology. Computed tomography scans of the skull specimens were obtained to explore radiological landmarks for different types of MCPs. Illustrative intraoperative videos were also analyzed in the light of these crucial surgical landmarks.RESULTSThe sample included 2250 specimens from males and 476 from females. Specimens were classified as either “white” (60.5%) or “black” (39.2%). An MCP was found in 42% of specimens, with 60% of those specimens presenting bilaterally. Fully ossified CCR comprised 27% of all MCPs, and contact (defined as contact without ossification between MCP and anterior clinoid process) comprised 4% of all MCPs. White race (relative to black race) and increasing age were significant predictors of MCP presence (p < 0.001). White race was significantly associated with greater average MCP height (p < 0.001). Among skulls with CCR, both male sex and older age (> 70 years relative to < 50 years) were associated with increased CCR diameter (p < 0.001). No other significant predictors or associations were observed. The CT scans of skulls replicated and validated the authors’ morphometric observations on incomplete, contact, and CCR patterns adequately. The surgical strategies of clinoid bone removal are validated, with appropriate video illustrations.CONCLUSIONSVariations in the patterns of bony MCPs can pose a significant risk for injury to the internal carotid artery during parasellar procedures, especially those involving clinoidectomy and optic strut drilling. Understanding parasellar anatomy, especially on skull-base CT imaging, may be integral to surgical planning and preoperative risk counseling in both transcranial and extended endonasal procedures, as well as to preparing for complications management perioperatively.
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Affiliation(s)
| | | | - Joseph E. Tanenbaum
- 1Case Western Reserve University School of Medicine
- 2Department of Epidemiology and Biostatistics, Case Western Reserve University; and
| | | | - Nakao Ota
- 4Department of Neurosurgery, Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | | | - Sunil Manjila
- 6Department of Neurosciences, McLaren Bay Neurosurgery Associates, Bay City, Michigan
| | - Amin Kassam
- 5Aurora Neurosciences Center, Milwaukee, Wisconsin; and
| | - Bulent Yapicilar
- 1Case Western Reserve University School of Medicine
- 7Neurosurgery, MetroHealth Medical Center, Cleveland, Ohio
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Rahme RJ, Arnaout OM, Sanusi OR, Kesavabhotla K, Chandler JP. Endoscopic Approach to Clival Chordomas: The Northwestern Experience. World Neurosurg 2017; 110:e231-e238. [PMID: 29104156 DOI: 10.1016/j.wneu.2017.10.146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Chordomas are rare primary bone tumors with a low-grade histology but an aggressive clinical behavior characterized by local invasion and recurrence. When occurring in the skull base, their treatment is limited by proximity to critical neurovascular structures. Open surgical approaches can carry high morbidity, making the development of alternative approaches desirable. We describe our experience with endoscopic endonasal approaches to clival chordomas over 13 years. METHODS We performed a retrospective chart review of patients diagnosed with clival chordomas and treated with an endoscopic endonasal approach between 2003 and 2015 at Northwestern Memorial Hospital. We reviewed presenting symptoms, tumor location and size, extent of resection, complications, recurrence, adjuvant treatment, retreatment, and follow-up duration. RESULTS A total of 23 charts were reviewed, with 17 included in our final review. Mean age was approximately 48 years. The most common presenting symptom was diplopia present in 70.6% of patients. Mean tumor volume was 20.2 cm3. Gross total resection was achieved in 52.9% of patients. With a mean follow-up period of 63.4 months, 5 patients had a recurrence. The most common complication was cerebrospinal fluid (CSF) leak, which was noted in 6 patients. Tumor volume was significantly higher in patients with CSF leak. No correlation between intradural extension and postoperative CSF leak was noted. CONCLUSIONS Clival chordoma are challenging entities to treat. The best outcomes are achieved with gross total resection followed by adjuvant radiotherapy treatment. We show that the endonasal endoscopic corridor is a viable alternative approach to these lesions.
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Affiliation(s)
- Rudy J Rahme
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine and McGaw Medical Center, Chicago, Illinois, USA
| | - Omar M Arnaout
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine and McGaw Medical Center, Chicago, Illinois, USA; Department of Neurological Surgery, Brigham and Women's Hospital, Harvard School of Medicine, Boston, Massachusetts, USA
| | - Olabisi R Sanusi
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine and McGaw Medical Center, Chicago, Illinois, USA
| | - Kartik Kesavabhotla
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine and McGaw Medical Center, Chicago, Illinois, USA
| | - James P Chandler
- Departments of Neurological Surgery, Otolaryngology, and Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA.
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Konuthula N, Khan MN, Del Signore A, Govindaraj S, Shrivastava R, Iloreta AM. A Systematic Review of Secondary Cerebrospinal Fluid Leaks. Am J Rhinol Allergy 2017; 31:48-56. [DOI: 10.2500/ajra.2017.31.4487] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Secondary cerebrospinal leaks (CSF) are leaks that recur after an initial endoscopic repair of CSF leaks. Identification of characteristics that could predict secondary leaks may allow surgeons to plan repairs with the knowledge that these defects are more likely to fail. Objective To identify characteristics that could predict secondary CSF leaks. Methods A search of all studies that reported outcomes after endoscopic repair of CSF leaks was conducted by using medical literature data bases. Studies with the following criteria were included: written in the English language, secondary CSF leaks after primary repair, and assessment of success of fistula repair. Data extracted included the etiology of the leak, site of the leak, reconstructive materials used, and success of the repair. Results Ninety-four studies, from 1988 to 2015, with a total of 3149 primary CSF leaks were included. Sixty-three studies (67%) had a success rate of ≥80%; 77 studies (82%) had secondary leak rates of <40%. For 88 of the 94 studies (94%), the success rate after secondary repair improved to 81.0–100%. Of 48 studies that included leaks of more than one site, the sphenoid was the most common site of leak in 26 studies (55%), the ethmoid was the most common site in 16 studies (34%), and the cribriform was the most common site in 11 studies (23%). Conclusion The rate of secondary CSF leaks was low due to advances in endoscopic repair techniques. Spontaneous and iatrogenic CSF leaks were more likely to recur, especially without adequate control of underlying factors, such as increased intracranial pressure and obesity. Further studies with consistent reporting are required for more definitive conclusions about secondary CSF leaks.
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Affiliation(s)
- Neeraja Konuthula
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
| | - Mohemmed N. Khan
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
| | - Anthony Del Signore
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Beth Israel, New York, New York
| | - Satish Govindaraj
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
| | - Raj Shrivastava
- Department of Neurosurgery—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
| | - Alfred M. Iloreta
- Department of Otolaryngology—Head and Neck Surgery, Mount Sinai Medical Center, New York, New York
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Li XS, Yang WL, Shen FZ, Gao GJ, Ma JW, Jin BZ. Short-term therapeutic effects of low-dose cytarabine plus surgical resection on elderly patients with trigeminal nerve tumor and safety observation. Pak J Med Sci 2015; 31:178-82. [PMID: 25878639 PMCID: PMC4386182 DOI: 10.12669/pjms.311.6440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Revised: 11/17/2014] [Accepted: 11/17/2014] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the short-term therapeutic effects of low-dose cytarabine plus surgical resection on elderly patients with trigeminal nerve tumor and to observe the safety. METHODS A total of 120 elderly patients with trigeminal nerve tumor were divided into a treatment group and a control group by random draw (n=60), and both groups were subjected to resection by stereotactic image-guided endoscopic nasal surgery. Afterwards, the control group was administered with high-dose cytarabine while the treatment group was given low-dose cytarabine for 14 days. RESULTS Both groups completed treatment, but the effective rate of the treatment group (96.7%) was significantly higher than that of the control group (83.3%) (P < 0.05). The pain scores of the two groups were similar at T0, T1 and T2, but the score of the treatment group at T2 was significantly different from those at T0 and T1 (P < 0.05). During treatment, the treatment group was significantly less prone to complications such as headache, vomiting, vision impairment, nausea and local swelling than the control group (P < 0.05). During three months of follow-up, the appetite, sleep and daily living scores were significantly higher than those of the control group (P < 0.05). CONCLUSION Stereotactic image-guided surgery was able to treat trigeminal nerve tumor well, and the effect was enhanced by low-dose cytarabine that improved postoperative outcomes and quality of life by dramatically decreasing complications.
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Affiliation(s)
- Xiang-Sheng Li
- Xiang-Sheng Li, Department of Neurosurgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, PR China
| | - Wei-Long Yang
- Wei-Long Yang, Department of Neurosurgery, The Third Affiliated Hospital of Xinxiang Medical University, Xinxiang 453003, PR China
| | - Fa-Zheng Shen
- Fa-Zheng Shen, Department of Neurosurgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, PR China
| | - Guo-Jun Gao
- Guo-Jun Gao, Department of Neurosurgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, PR China
| | - Ji-Wei Ma
- Ji-Wei Ma, Department of Neurosurgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, PR China
| | - Bao-Zhe Jin
- Bao-Zhe Jin, Department of Neurosurgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui 453100, PR China
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