Results with Expanded Endonasal Resection of Skull Base Meningiomas Technical Nuances and Approach Selection Based on an Early Experience

Visual outcomes in tuberculum sellae meningiomas comparing transcranial and endoscopic endonasal approaches

Background

Tuberculum sellae meningiomas (TSM) account for 3-10% of intracranial meningiomas. Visual loss is the presenting symptom in up to 80% of cases. Surgical management poses a great challenge due to tumor proximity to neurovascular structures such as the optic nerve and the internal carotid artery (ICA); hence, there is controversy regarding the optimal approach. The aim of this study is to determine differences in visual outcomes between transcranial (TCA) and endoscopic endonasal (EEA) approaches.

Methods

A retrospective study including 29 patients with TSM surgically treated by TCA or EEA between 2011 and 2023 in a single referral center was conducted. Pre-and post-operative neuro-ophthalmologic evaluations, focusing on visual acuity and campimetry, were evaluated.

Results

Sixteen (55.16%) patients were intervened through a TCA and the remaining 13 (44.84%) via an EEA. The lesions in each group were similar in terms of pre- operative volume (15.12 vs 12.9 cm3, p = 0.497) and neurovascular invasion (optic canal invasion 48.26 vs 41.37%, p = 0.664; ICA 44.81 vs 31.03%, p = 0.797). There were no significant differences in visual outcomes between both approaches; TCA presented an improvement of 5.18 points in visual fields (p = 0.140), whereas EEA had an improvement of 17.39 points in visual acuity (p = 0.114).

Conclusion

EEA seems to offer greater improvement in visual acuity than TCA. However, the ideal approach should be individualized; taking into account the tumor's volume and invasiveness, as well as the patient's visual complaints.

Endoscopic Endonasal Transpterygoid Approach and the Need for Myringotomy

OBJECTIVE

The expanded endonasal transpterygoid approach (EETA) is used to access the middle and posterior fossa through the pterygoid process. Traditionally, the eustachian tube (ET) was resected during EETA, which often required subsequent myringotomy for inner ear drainage. Anterolateral transposition of the ET was proposed to decrease potential morbidity associated with resection. However, a comparison of resection versus transposition regarding the need for subsequent myringotomy has not been reported.

METHODS

This is a retrospective cohort study of patients who underwent an EETA. Patient demographics, tumor characteristics, management of ET with resection versus transposition, and need for subsequent myringotomy were collected. Analysis was performed with JMP software in standard fashion and univariate and multivariate logistic regression analysis performed with a p < 0.05 was considered significant.

RESULTS

Ninety-one patients underwent EETA for various malignant and benign tumors. Twenty-seven patients required myringotomy, with tumors of the pterygopalatine fossa accounting for the most common location (n = 8). Malignant pathology had the highest myringotomy rate compared to benign tumors (48.9% vs. 10.9%, p < 0.001), as did receiving postoperative radiation (p < 0.001), ET resection (p < 0.001), and increasing CPK class. Multivariate analysis of these variables suggests that only ET resection significantly correlated with the need for myringotomy (LR 7.97, p = 0.005).

CONCLUSIONS

ET resection during EETA can lead to ET dysfunction and require myringotomy post-operatively, and patients should be counseled of this risk. Radiation treatment, malignant pathology, and CPK class, all reflecting situations where more extensive surgery was needed, were associated with the need for myringotomy on univariate analysis but did not reach significance with multivariate analysis.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1203-1207, 2024.

Midline Skull Base Meningiomas: Transcranial and Endonasal Perspectives

Simple Summary

Skull base meningiomas have always represented a challenge for neurosurgeons. Despite their histological nature, they may be associated with unfavorable outcomes due to their deep-seated location and the surrounding neurovascular structures. Over time, several corridors have been proposed, each one carrying its own pros and cons. During the last decades, the endoscopic endonasal route has been asserted among the classic routes for a growing number of midline and paramedian lesions. Therefore, the aim of our paper is to present a comprehensive review of the indications and techniques for the management of skull base meningiomas, emphasizing the ambivalent and complementary role of the low and high routes.

Abstract

Skull base meningiomas have always represented a challenge for neurosurgeons. Despite their histological nature, they may be associated with unfavorable outcomes due to their deep-seated location and the surrounding neurovascular structures. The state of the art of skull base meningiomas accounts for both transcranial, or high, and endonasal, or low, routes. A comprehensive review of the pertinent literature was performed to address the surgical strategies and outcomes of skull base meningioma patients treated through a transcranial approach, an endoscopic endonasal approach (EEA), or both. Three databases (PubMed, Ovid Medline, and Ovid Embase) have been searched. The review of the literature provided 328 papers reporting the surgical, oncological, and clinical results of different approaches for the treatment of skull base meningiomas. The most suitable surgical corridors for olfactory groove, tuberculum sellae, clival and petroclival and cavernous sinus meningiomas have been analyzed. The EEA was proven to be associated with a lower extent of resection rates and better clinical outcomes compared with transcranial corridors, offering the possibility of achieving the so-called maximal safe resection.

The endoscope-assisted supraorbital "keyhole" approach for anterior skull base meningiomas: an updated meta-analysis

INTRODUCTION

The gold-standard treatment for symptomatic anterior skull base meningiomas is surgical resection. The endoscope-assisted supraorbital "keyhole" approach (eSKA) is a promising technique for surgical resection of olfactory groove (OGM) and tuberculum sellae meningioma (TSM) but has yet to be compared with the microscopic transcranial (mTCA) and the expanded endoscopic endonasal approach (EEA) in the context of existing literature.

METHODS

An updated study-level meta-analysis on surgical outcomes and complications of OGM and TSM operated with the eSKA, mTCA, and EEA was conducted using random-effect models.

RESULTS

A total of 2285 articles were screened, yielding 96 studies (2191 TSM and 1510 OGM patients). In terms of effectiveness, gross total resection incidence was highest in mTCA (89.6% TSM, 91.1% OGM), followed by eSKA (85.2% TSM, 84.9% OGM) and EEA (83.9% TSM, 82.8% OGM). Additionally, the EEA group had the highest incidence of visual improvement (81.9% TSM, 54.6% OGM), followed by eSKA (65.9% TSM, 52.9% OGM) and mTCA (63.9% TSM, 45.7% OGM). However, in terms of safety, the EEA possessed the highest cerebrospinal fluid leak incidence (9.2% TSM, 14.5% OGM), compared with eSKA (2.1% TSM, 1.6% OGM) and mTCA (1.6% TSM, 6.5% OGM). Finally, mortality and intraoperative arterial injury were 1% or lower across all subgroups.

CONCLUSIONS

In the context of diverse study populations, the eSKA appeared not to be associated with increased adverse outcomes when compared with mTCA and EEA and offered comparable effectiveness. Case-selection is paramount in establishing a role for the eSKA in anterior skull base tumours.

Primary and Secondary Optic Nerve Sheath Meningioma

Objective  This study was aimed to review issues relating to the recognition, radiographic diagnosis, monitoring, and management of primary and secondary optic nerve sheath meningioma (ONSM). Design  This study is a review of peer-reviewed literature combined with illustrative case studies. Participants and Methods  A literature search was conducted via the PubMed database using pertinent search terms. Selected articles were limited to those written or translated into English. Additional works cited within articles were also included. Individual cases were drawn from the experience of a tertiary academic neuroophthalmic and orbital practice. Tables summarize radiotherapeutic and surgical studies, excluding single case reports and studies focusing on meningioma of intracranial origin. Main Outcome Measurements  Review of reported surgical and radiotherapeutic series is the primary measurement. Results  The natural history of optic nerve sheath meningiomas is primarily characterized by progressive ipsilateral vision loss. Diagnosis is typically based on radiographic imaging findings, with biopsy remaining indicated in some patients. Management strategies may include observation, radiation, and/or surgical intervention, or a combination of these approaches. The role of surgery, especially with respect to primary ONSM (pONSM), remains controversial. Advancement of radiotherapy techniques has shifted modern treatment paradigms in pONSM toward radiation as primary treatment, as surgical outcomes are inferior in major studies. Although radiation remains the treatment of choice in many cases, selected patients may benefit from surgery, especially in the setting of secondary ONSM (sONSM). Conclusion  A wide variety of radiotherapeutic and surgical treatment modalities for ONSM exist. The specific indications for each management strategy continue to be redefined.

Endoscopic endonasal approach for suprasellar meningiomas: introduction of a new scoring system to predict extent of resection and assist in case selection with long-term outcome data

OBJECTIVE

The endoscopic endonasal approach (EEA) has gained increasing popularity for the resection of suprasellar meningiomas (SSMs). Appropriate case selection is critical in optimizing patient outcome. Long-term outcome data are lacking. The authors systematically identified preoperative factors associated with extent of resection (EOR) and determined the relationship between EOR and long-term recurrence after EEA for SSMs.

METHODS

In this retrospective cohort study, the authors identified preoperative clinical and imaging characteristics associated with EOR and built on the recently published University of California, San Francisco resectability score to propose a score more specific to the EEA. They then examined the relationship between gross-total resection (GTR; 100%), near-total resection (NTR; 95%-99%), and subtotal resection (STR; < 95%) and recurrence or progression with Kaplan-Meier survival analysis.

RESULTS

A total of 51 patients were identified. Radiographic GTR was achieved in 40 of 47 (85%) patients in whom it was the surgical goal. Significant independent risk factors for incomplete resection were prior surgery (OR 25.94, 95% CI < 2.00 to 336.49, p = 0.013); tumor lateral to the optic nerve (OR 13.41, 95% CI 1.82-98.99, p = 0.011); and complete internal carotid artery (ICA) encasement (OR 15.12, 95% CI 1.17-194.08, p = 0.037). Tumor size and optic canal invasion were not significant risk factors after adjustment for other variables. A resectability score based on the multivariable model successfully predicted the likelihood of GTR; a score of 0 had a positive predictive value of 97% for GTR, whereas a score of 2 had a negative predictive value of 87.5% for incomplete resection. After a mean follow-up of 40.6 ± 32.4 months (mean ± SD), recurrence was 2.7% after GTR (1 patient with atypical histology), 44.4% after NTR, and 80% after STR (p < 0.0001). Vision was stable or improved in 93.5% and improved in 67.4% of patients with a preoperative deficit. There were 5 (9.8%) postoperative CSF leaks, of which 4 were managed with lumbar drains and 1 required a reoperation.

CONCLUSIONS

The EEA is a safe and effective approach to SSMs, with favorable visual outcomes in well-selected cases. The combination of postoperative MRI-based EOR with direct endoscopic inspection can be used in lieu of Simpson grade to predict recurrence. GTR dramatically reduces recurrence and can be achieved regardless of tumor size, proximity or encasement of the anterior cerebral artery, or medial optic canal invasion. Risk factors for incomplete resection include prior surgery, tumor lateral to the optic nerve, and complete ICA encasement.

The endoscopic endonasal approach is not superior to the microscopic transcranial approach for anterior skull base meningiomas-a meta-analysis

Object

In the past decade, the endonasal transsphenoidal approach (eTSA) has become an alternative to the microsurgical transcranial approach (mTCA) for tuberculum sellae meningiomas (TSMs) and olfactory groove meningiomas (OGMs). The aim of this meta-analysis was to evaluate which approach offered the best surgical outcomes.

Methods

A systematic review of the literature from 2004 and meta-analysis were conducted in accordance with the PRISMA guidelines. Pooled incidence was calculated for gross total resection (GTR), visual improvement, cerebrospinal fluid (CSF) leak, intraoperative arterial injury, and mortality, comparing eTSA and mTCA, with p-interaction values.

Results

Of 1684 studies, 64 case series were included in the meta-analysis. Using the fixed-effects model, the GTR rate was significantly higher among mTCA patients for OGM (eTSA: 70.9% vs. mTCA: 88.5%, p-interaction < 0.01), but not significantly higher for TSM (eTSA: 83.0% vs. mTCA: 85.8%, p-interaction = 0.34). Despite considerable heterogeneity, visual improvement was higher for eTSA than mTCA for TSM (p-interaction < 0.01), but not for OGM (p-interaction = 0.33). CSF leak was significantly higher among eTSA patients for both OGM (eTSA: 25.1% vs. mTCA: 10.5%, p-interaction < 0.01) and TSM (eTSA: 19.3%, vs. mTCA: 5.81%, p-interaction < 0.01). Intraoperative arterial injury was higher among eTSA (4.89%) than mTCA patients (1.86%) for TSM (p-interaction = 0.03), but not for OGM resection (p-interaction = 0.10). Mortality was not significantly different between eTSA and mTCA patients for both TSM (p-interaction = 0.14) and OGM resection (p-interaction = 0.88). Random-effect models yielded similar results.

Conclusion

In this meta-analysis, eTSA was not shown to be superior to mTCA for resection of both OGMs and TSMs.

Electronic supplementary material

The online version of this article (10.1007/s00701-017-3390-y) contains supplementary material, which is available to authorized users.