Endoscopic Endonasal Supraoptic and Infraoptic Approaches for Complex "Parasuprasellar" Lesions: Surgical Anatomy, Technique Nuances, and Case Series

Endoscopic Endonasal Internal Carotid Artery Transposition Technique in Tumor With Parasellar Extension: A Single-Center Experience

BACKGROUND AND OBJECTIVES

Lateralization or mobilization of the internal carotid artery (ICA) during a midline approach is required to expose lesions behind or lateral to the ICA. However, there have been no published data regarding the surgical outcomes of the endoscopic endonasal internal carotid transposition technique (EEITT). This study aimed to analyze the relevant surgical anatomy around the ICA and propose a grading scheme of EEITT.

METHODS

A retrospective review of patients who underwent EEITT at a single institution was performed. Based on structures that limited the ICA and intraoperative findings, an anatomically surgical grading scheme of EEITT was proposed.

RESULTS

Forty-two patients (mean age 45.6 years, 57.1% female patients) were included. Of them, 29 cases (69.0%) were Knosp grade 4 pituitary adenoma, 6 cases (14.3%) were chordoma, 6 cases (14.3%) were meningioma, and a single case (2.4%) was meningeal IgG4-related disease. The EEITT was categorized into Grades 1, 2 and 3, which was used in 24 (57.1%), 12 (28.6%), and 6 (14.3%) cases, respectively. The most common symptom was visual disturbance (45.2%). The gross total resection rate in Grade 1 (79.2%) and Grade 2 (83.3%) was much higher than that in Grade 3 (66.6%). The overall rate of visual function improvement, preoperative cranial nerve (CN) palsy improvement, and postoperative hormonal remission was 89.4%, 85.7%, and 88.9%, respectively. The rate for the following morbidities was cerebrospinal fluid leakage, 2.4%; permanent diabetes insipidus, 4.8%; new transient CN palsy, 9.5%; permanent CN palsy, 4.7%; panhypopituitarism, 7.1%; and ICA injury, 2.4%.

CONCLUSION

The EEITT is technically feasible and could be graded according to the extent of disconnection of limiting structures. For complex tumor with parasellar extensions, the distinction into Grades 1, 2, and 3 will be of benefit to clinicians in predicting risks, avoiding complications, and generating tailored individualized surgical strategies.

Endoscopic endonasal approach for optic Pathway-Hypothalamic Glioma: A pediatric case Report and a Systematic review

BACKGROUND

The Endoscopic Endonasal Approach (EEA) has revolutionized the treatment landscape for optic pathway-hypothalamic gliomas (OPHGs) by providing precise visualization of the lesion neuroanatomic and minimizing brain manipulation. Despite the variable clinical trajectories of OPHGs, the optimal management neurosurgical strategy continues to be a subject of debate.

METHODS

We present a case of an 8-year-old female with an OPHG who underwent EEA and performed a systematic review search in English and Spanish case reports from January 2007 (date of first reported case) to June 2024, focusing on OPHG treated with EEA. Databases such as PubMed, Lilacs, and Embase.

SEARCH RESULTS

Our systematic review encompassed 30 cases of OPHGs treated with EEA. Most patients (86.6%) presented with visual disturbance, 43.3% with headaches, and 30% with endocrine disturbances. Gross-total resection (GTR) was achieved in 20%, subtotal in 40%, and near-total in 20%. Histologically, pilocytic astrocytoma predominated (73.3%), with varied clinical presentations highlighting the need for tailored management approaches.

CONCLUSIONS

The EEA offers safe access to the optic pathway and hypothalamic region. Despite limitations in achieving GTR compared to other approaches, EEA's benefits in clinical improvement and neuroanatomical preservation make it a valuable option for select cases of OPHGs.

Distinction of papillary and adamantinomatous craniopharyngioma: Clinical features, surgical nuances and hypothalamic outcomes

OBJECTIVE

Understanding the differences of suprasellar papillary and adamantinomatous craniopharyngiomas (PCPs/ACPs) is pivotal for target therapy, surgical strategy or postoperative management. Here, the clinical features, surgical nuances and postoperative hypothalamic outcomes of PCPs were systematically recapitulated.

METHODS

24 PCPs and 52 ACPs underwent initial surgery were retrospectively reviewed. Clinical data, quantified third ventricle (3rd V) occupation and optic chiasm distortion were compared, as well as intra-operative findings, operating notes and prognosis. Moreover, analysis of tumor/3rd V relationship and hypothalamic outcomes were also performed.

RESULTS

Tumors were more likely to occupies the 3rd V cavity in PCPs. Chiasm distortion of "compressed forward" was the most common pattern (45.8 %) in PCPs, whereas "stretched forward" pattern accounted the highest (42.5 %) in ACPs. Besides, round-shaped with less calcification, duct-like recess, solid consistency, rare subdiaphragmatic invasion, visible lower stalk and improved postoperative visual outcome were more frequently observed in PCPs. The basal membranes of the tumor epithelium and the reactive gliosis were separated by a layer of collagen fibers in most PCPs, which differs from ACPs in the morphological examination of tumor/3rd V floor interface. In daytime sleepiness and memory difficulty, the PCPs showed significantly better outcomes than the ACPs groups, and PCPs suffered less postoperative weight gain (p < 0.05) than ACPs among adult-onset cases.

CONCLUSION

PCPs are different from ACPs regards the clinical features, operative techniques and outcomes. If necessary, PCPs are suggested more amenable to total removal since its less invasiveness to the 3rd V floor and better hypothalamic outcomes.

Surgical treatment of a giant paraophthalmic aneurysm postfailed flow diversion through endoscopic endonasal approach: Technical nuances and review of the literature

Background

Giant internal carotid artery (ICA) aneurysms are usually treated through flow diversion, coiling, or a combination of both. However, certain cases that fail the endovascular treatment pose a technical challenge.

Case Description

A 68-year-old male presented with gradual visual changes affecting his right eye and was found to have a giant unruptured right paraophthalmic aneurysm. The aneurysm showed growth, and the patient's symptoms worsened despite coiling and flow diversion. Due to the location of this aneurysm and persistent compression of the optic chiasm by the coil mass, his right ICA was sacrificed, and an expanded endoscopic endonasal approach was successfully used to clip the residual aneurysm, remove the coil mass, and thus, decompress the optic chiasm. The patient's visual symptoms improved after that, and post clipping imaging demonstrated adequate occlusion of his right paraophthalmic aneurysm.

Conclusion

Recognizing the option of an endoscopic endonasal approach for clipping giant internal carotid aneurysms is of great importance. This approach can be safe and technically successful for the treatment of paraophthalmic aneurysms that fail the typical endovascular treatment.

Operative management of trigeminal schwannomas: based on a modified classification in a study of 93 cases

BACKGROUND

Advances in microscopic and endoscopic surgical techniques have outpaced traditional classification and transcranial surgical strategies, especially with reference to the treatment of trigeminal schwannomas (TSs). A modified TS classification is proposed and appropriate surgical strategies are discussed.

METHODS

The cases of 93 patients who underwent surgical treatment in Beijing Tiantan Hospital in the previous 6 years were analyzed retrospectively, and a literature review was conducted.

RESULTS

Classification is based on surgical direction. Tumors were classified as follows: type A, backward orientation, located in the orbit or orbit and middle cranial fossa (8 cases, 8.6%); type B, upward orientation, located in the pterygopalatine fossa, infratemporal fossa or pterygopalatine fossa, infratemporal fossa, and middle cranial fossa (23 cases, 24.7%); type C, forward and backward orientations, located in the middle cranial fossa, posterior cranial fossa or both (58 cases, 62.4%); and type D, located in multiple regions (4 cases, 4.3%). 91.40% of patients underwent gross total resection (GTR) with 29 cases receiving endoscopic resection of whom 93.10% (27/29) experienced GTR.

CONCLUSION

The 93 cases were satisfactorily divided into four types, according to tumor location and surgical orientation, enabling safe and effective removal by appropriate surgery.