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Mongkolkul K, Salem EH, Alsavaf MB, Prevedello DM, Vankoevering K, Kelly K, Carrau RL. Advantages and caveats of endoscopic to the infratemporal fossa as isolated and combined techniques. Laryngoscope Investig Otolaryngol 2024; 9:e1242. [PMID: 38736945 PMCID: PMC11081421 DOI: 10.1002/lio2.1242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/07/2024] [Accepted: 03/16/2024] [Indexed: 05/14/2024] Open
Abstract
Objective Identify the benefits and caveats of combining minimal access approaches to the infratemporal fossa (ITF), such as the endoscopic transnasal, endoscopic transorbital, endoscopic transoral, and endoscopic sublabial transmaxillary approaches to address extensive lesions not amenable to a single approach. The study provides anatomical metrics including area of exposure and degree of surgical freedom. Methods Five human cadaveric specimens (10 sides) were dissected to expose and methodically analyze the anatomical intricacies of the ITF using the following minimal access approaches: endoscopic transnasal transpterygoid (EETA), endoscopic sublabial transmaxillary, endoscopic transorbital via infraorbital foramen, and endoscopic transoral techniques. Area of exposure at the pterygopalatine fossa and surgical freedom at the ITF were obtained for each approach. Results The endoscopic sublabial transmaxillary sinus and the combined approach afford a significantly greater exposure than an isolated EETA. The difference in exposure (mean) between the endoscopic sublabial transmaxillary and EETA was 1.62 ± 0.85 cm2 (p < 0.001), and the difference between the combined approach and EETA was 4.25 ± 0.85 cm2 (p < 0.001). Conclusions Combining minimal access endoscopic approaches to the ITF can provide significantly greater exposure than an isolated EETA; thus, providing enhanced access to address lesions with extensive involvement of the ITF, especially those with superolateral and inferolateral extensions. In addition, some approaches may have an adjunctive role to the resection, such as the endoscopic transoral approach offering the potential for early control of the internal maxillary artery and its branches, some of which may be supplying the tumor in the ITF; or the endoscopic transorbital approach yielding a direct line of sight to the superior ITF and middle cranial fossa. Level of Evidence NA.
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Affiliation(s)
- Kittichai Mongkolkul
- Excellence Center in Otolaryngology Head & Neck SurgeryRajavithi HospitalBangkokThailand
- Rangsit University College of MedicineMueang Pathum ThaniThailand
| | - Eman H. Salem
- Otorhinolaryngology‐Head and Neck SurgeryMansoura University HospitalsMansouraEgypt
| | - Mohammad Bilal Alsavaf
- Otolaryngology‐Head and Neck SurgeryThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | | | | | - Kathleen Kelly
- Otolaryngology‐Head and Neck SurgeryThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Ricardo L. Carrau
- Otolaryngology‐Head and Neck SurgeryThe Ohio State University Wexner Medical CenterColumbusOhioUSA
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Khaleghi M, Otto B, Carrau R, Abouammo MD, Prevedello DM. Correction to: Customized ventral bony and dural opening in the transplanum/transtuberculum and transclival variants of extended endoscopic endonasal approach to suprasellar craniopharyngiomas: an approach‑based stepwise cadaveric dissection and clinical applicability. Acta Neurochir (Wien) 2024; 166:205. [PMID: 38713321 DOI: 10.1007/s00701-024-06095-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Affiliation(s)
- Mehdi Khaleghi
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Bradly Otto
- Department of Otolaryngology‑Head & Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Ricardo Carrau
- Department of Otolaryngology‑Head & Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Moataz D Abouammo
- Department of Otolaryngology‑Head & Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
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Khaleghi M, Carlstrom LP, Prevedello DM. Unusual Atrophic Nervus Intermedius in a Patient with Refractory Nervus Intermedius Neuralgia and History of Ipsilateral Sudden-Onset Central Facial Palsy and Sensorineural Hearing Loss: Cadaveric-Clinical Images with Surgical Video. World Neurosurg 2024; 185:91-94. [PMID: 38340797 DOI: 10.1016/j.wneu.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/02/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024]
Abstract
Nervus intermedius (NI) arises from the superior salivary nucleus, solitary nucleus, and trigeminal tract. It leaves the pons as 1 to 5 roots and travels between the facial and vestibulocochlear nerves before merging with the facial nerve within the internal auditory canal. The mastoid segment of the facial nerve then gives rise to a sensory branch that supplies the posteroinferior wall of the external auditory meatus and inferior pina. This complex pathway renders the nerve susceptible to various pathologies, leading to NI neuralgia. Here, the authors present an unusual intraoperative finding of an atrophic NI in a patient with refractory NI neuralgia and a history of ipsilateral sudden-onset central facial palsy and microvascular decompression for trigeminal neuralgia. The patient underwent NI sectioning via the previous retrosigmoid window and achieved partial ear pain improvement. The gross size of the NI is compared with a cadaveric specimen through stepwise dissection. This case highlights the potential significance of subtle central ischemic events and subsequent atrophy of NI in the pathogenesis of NI neuralgia, as well as the ongoing need to investigate the therapeutic efficacy of nerve sectioning.
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Affiliation(s)
- Mehdi Khaleghi
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Lucas P Carlstrom
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA.
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4
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Damante MA, Magill ST, Kreatsoulas D, McGahan BG, Finger G, Hatef J, Hatef A, Carrau RL, Hardesty DA, Prevedello DM. A modern approach to olfactory groove meningiomas. J Neurosurg 2024; 140:1215-1222. [PMID: 37948686 DOI: 10.3171/2023.8.jns2318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/30/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Management of olfactory groove meningiomas (OGMs) has changed significantly with the advances in extended endoscopic endonasal approaches (EEAs), which is an excellent approach for patients with anosmia since it allows early devascularization and minimizes retraction on the frontal lobes. Craniotomy is best suited for preservation of olfaction. However, not infrequently, a tumor presents after extending outside the reach of an EEA and a solely transcranial approach would require manipulation and retraction of the frontal lobes. These OGMs may best be treated by a staged EEA-craniotomy approach. In this study the authors' goal was to present their case series of patients with OGMs treated with their surgical approach algorithm. METHODS The authors conducted an IRB-approved, nonrandomized historic cohort including all consecutive cases of OGMs treated surgically between 2010 and 2020. Patient demographic information, presenting symptoms, operative details, and complications data were collected. Preoperative and postoperative tumor and T2/FLAIR intensity volumes were calculated using Visage Imaging software. RESULTS Thirty-one patients with OGMs were treated (14 craniotomy only, 11 EEA only, and 6 staged). There was a significant difference in the distribution of patients presenting with anosmia and visual disturbance by approach. Tumor size was significantly correlated with preoperative vasogenic edema. Gross-total resection was achieved in 90% of cases, with near-total resection occurring twice with EEA and once with a staged approach. T2/FLAIR hyperintensity completely resolved in 90% of cases and rates did not differ by approach. Complication rates were not significantly different by approach and included 4 CSF leaks (p = 0.68). CONCLUSIONS A staged approach for the management of large OGMs with associated anosmia and significant lateral extension is a safe and effective option for surgical management. Through utilization of the described algorithm, the authors achieved a high rate of GTR, and this strategy may be considered for large OGMs.
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Affiliation(s)
| | - Stephen T Magill
- Departments of1Neurosurgery
- 2Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | | | | | - Ricardo L Carrau
- 4Otolaryngology, The Ohio State Wexner Medical Center, Columbus, Ohio; and
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5
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Khaleghi M, Carlstrom LP, Callejas CA, Kobalka P, Carrau R, Prevedello DM. Modified Function-Preserving Endoscopic Endonasal Extracapsular Resection of a Large Orbital Apex Cavernous Hemangioma. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01135. [PMID: 38651862 DOI: 10.1227/ons.0000000000001157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/09/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND AND IMPORTANCE Various invasive oculoplastic procedures are commonly utilized to control the rectus muscles and widen the surgical corridor through the endoscopic endonasal removal of large orbital apex cavernous hemangiomas (OACHs). They require additional transconjunctival incision, rectus muscle insertional retraction, or muscle deinsertion at the globe that might not be safe and lead to prolonged postoperative extraocular muscle dysfunction. In this article, the authors described a modified 3-handed extracapsular technique for the resection of a large OACH without an additional procedure for rectus muscle control. The aim is to achieve a safe gross total tumor removal while minimizing the procedure-related complications. An intraoperative video is included, along with a stepwise cadaveric dissection relevant to the approach. CLINICAL PRESENTATION A 71-year-old female presented with progressive left-sided blurred vision, binocular diplopia, and mild proptosis. Contrast-enhanced brain MRI revealed a large heterogeneous enhanced inferomedial intraconal mass in the left orbital apex, mostly consistent with cavernous hemangioma. Gross total tumor removal was achieved through a modified 3-handed endoscopic endonasal extracapsular approach. The diplopia was resolved, and significant visual improvement was achieved. Computed tomography scan demonstrated complete tumor removal, and histological examination confirmed the diagnosis. CONCLUSION Endoscopic endonasal resection of large OACH can be feasibly performed by using a modified 3-handed extracapsular technique through the generous use of Q-tip swab applicators within the natural separation plane around the tumor capsule and a sequential traction-countertraction method. Subsequently, a gross total removal and optimal postoperative functional outcome are attainable through minimal rectus muscle fiber violation and intraconal fat manipulation.
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Affiliation(s)
- Mehdi Khaleghi
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Lucas P Carlstrom
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Claudio Andres Callejas
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Peter Kobalka
- Department of Pathology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Ricardo Carrau
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
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Shatara M, Blue M, Stanek J, Liu YA, Prevedello DM, Giglio P, Puduvalli VK, Gardner SL, Allen JC, Wong KK, Nelson MD, Gilles FH, Adams RH, Pauly J, O’Halloran K, Margol AS, Dhall G, Finlay JL. Final report of the phase II NEXT/CNS-GCT-4 trial: GemPOx followed by marrow-ablative chemotherapy for recurrent intracranial germ cell tumors. Neurooncol Pract 2024; 11:188-198. [PMID: 38496907 PMCID: PMC10940828 DOI: 10.1093/nop/npad067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024] Open
Abstract
Background Patients with relapsed intracranial germinoma can achieve durable remission with standard chemotherapy regimens and/or reirradiation; however, innovative therapies are required for patients with relapsed and/or refractory intracranial nongerminomatous germ cell tumors (NGGCTs) due to their poor prognosis. Improved outcomes have been reported using reinduction chemotherapy to achieve minimal residual disease, followed by marrow-ablative chemotherapy (HDCx) with autologous hematopoietic progenitor cell rescue (AuHPCR). We conducted a phase II trial evaluating the response and toxicity of a 3-drug combination developed for recurrent intracranial germ cell tumors consisting of gemcitabine, paclitaxel, and oxaliplatin (GemPOx). Methods A total of 9 patients with confirmed relapsed or refractory intracranial GCT were enrolled after signing informed consent, and received at least 2 cycles of GemPOx, of which all but 1 had relapsed or refractory NGGCTs. One patient with progressive disease was found to have pathologically confirmed malignant transformation to pure embryonal rhabdomyosarcoma (without GCT elements), hence was ineligible and not included in the analysis. Patients who experienced sufficient responses proceeded to receive HDCx with AuHPCR. Treatment response was determined based on radiographic tumor assessments and tumor markers. Results A total of 7 patients achieved sufficient response and proceeded with HDCx and AuHPCR, and 5 subsequently received additional radiotherapy. A total of 2 patients developed progressive disease while receiving GemPOx. Myelosuppression and transaminitis were the most common treatment-related adverse events. With a mean follow-up of 44 months, 4 patients (3 NGGCTs, 1 germinoma) are alive without evidence of disease. Conclusions GemPOx demonstrates efficacy in facilitating stem cell mobilization, thus facilitating the feasibility of both HDCx and radiotherapy.
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Affiliation(s)
- Margaret Shatara
- Division of Hematology and Oncology, St. Louis Children’s Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Megan Blue
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph Stanek
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Yin A Liu
- Departments of Ophthalmology, Neurology, and Neurosurgery, University of California, Davis, Sacramento, California, USA
| | - Daniel M Prevedello
- Department of Neurological Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Pierre Giglio
- Division of Neuro-Oncology, Ohio State University Wexner Medical Center, James Cancer Center, Columbus, Ohio, USA
| | - Vinay K Puduvalli
- Department of Neuro-oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Sharon L Gardner
- Department of Pediatrics, New York University Grossman School of Medicine, New York, New York, USA
| | - Jeffrey C Allen
- Department of Pediatrics, New York University Grossman School of Medicine, New York, New York, USA
| | - Kenneth K Wong
- Division of Hematology and Oncology, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles and Keck School of Medicine of University of Southern California, Los Angeles, California, USA
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Marvin D Nelson
- Department of Radiology, Children’s Hospital of Los Angeles, Los Angeles, California, USA
| | - Floyd H Gilles
- Department of Pathology, Children’s Hospital of Los Angeles, Los Angeles, California, USA
| | - Roberta H Adams
- Phoenix Children’s Center for Cancer & Blood Disorders, University of Arizona School of Medicine—Phoenix, and Mayo Clinic, Arizona, USA
| | - Jasmine Pauly
- Division of Hematology and Oncology, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, California, USA
| | - Katrina O’Halloran
- Division of Hematology and Oncology, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles and Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Ashley S Margol
- Division of Hematology and Oncology, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles and Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Girish Dhall
- Division of Pediatric Hematology/Oncology, Children’s Hospital of Alabama and the University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jonathan L Finlay
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children’s Hospital and Ohio State University College of Medicine, Columbus, Ohio, USA
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Gendreau JL, Kuo CC, Patel NA, Brown NJ, Pennington Z, Bui NE, Reardon T, Lien BV, Prevedello DM, Kuan EC, Hsu FP, Mohyeldin A. Staged Resection of Difficult-to-Treat Intracranial Meningiomas: A Systematic Review of the Indications, Surgical Approaches, and Postoperative Outcomes. J Neurol Surg B Skull Base 2024; 85:131-144. [PMID: 38449578 PMCID: PMC10914469 DOI: 10.1055/a-2015-8238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 01/09/2023] [Indexed: 01/21/2023] Open
Abstract
Introduction Meningiomas-the most common extra-axial tumors-are benign, slow-growing dural-based lesions that can involve multiple cranial fossae and can progress insidiously for years until coming to clinical attention secondary to compression of adjacent neurovascular structures. For complex, multicompartmental lesions, multistaged surgeries have been increasingly shown to enhance maximal safe resection while minimizing adverse sequela. Here, we systematically review the extant literature to highlight the merits of staged resection. Methods PubMed, Scopus, and Web of Science databases were queried to identify articles reporting resections of intracranial meningiomas using a multistaged approach, and articles were screened for possible inclusion in a systematic process performed by two authors. Results Of 118 identified studies, 36 describing 169 patients (mean age 42.6 ± 21.3 years) met inclusion/exclusion criteria. Petroclival lesions comprised 57% of cases, with the most common indications for a multistaged approach being large size, close approximation of critical neurovascular structures, minimization of brain retraction, identification and ligation of deep vessels feeding the tumor, and resection of residual tumor found on postoperative imaging. Most second-stage surgeries occurred within 3 months of the index surgery. Few complications were reported and multistaged resections appeared to be well tolerated overall. Conclusions Current literature suggests multistaged approaches for meningioma resection are well-tolerated. However, there is insufficient comparative evidence to draw definitive conclusions about its advantages over an unstaged approach. There are similarly insufficient data to generate an evidence-based decision-making framework for when a staged approach should be employed. This highlights the need for collaborative efforts among skull base surgeons to establish an evidentiary to support the use of staged approaches and to outline those indications that merit such an approach.
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Affiliation(s)
- Julian L. Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, United States
| | - Cathleen C. Kuo
- Jacobs School of Medicine and Biomedical Science, University at Buffalo, Buffalo, New York, United States
| | - Neal A. Patel
- School of Medicine, Mercer University School of Medicine, Savannah, Georgia, United States
| | - Nolan J. Brown
- Department of Neurosurgery, University of California, Irvine, Orange, California, United States
| | - Zach Pennington
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Nicholas E. Bui
- Loma Linda University School of Medicine, Loma Linda, California, United States
| | - Taylor Reardon
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, Kentucky, United States
| | - Brian V. Lien
- Department of Neurosurgery, University of California, Irvine, Orange, California, United States
| | - Daniel M. Prevedello
- Department of Neurosurgery, The Ohio State University, Columbus, Ohio, United States
| | - Edward C. Kuan
- Department of Neurosurgery, University of California, Irvine, Orange, California, United States
- Department of Otolaryngology, University of California, Irvine, Orange, California, United States
| | - Frank P.K. Hsu
- Department of Neurosurgery, University of California, Irvine, Orange, California, United States
| | - Ahmed Mohyeldin
- Department of Neurosurgery, University of California, Irvine, Orange, California, United States
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Bhuskute GS, Gosal JS, Alsavaf MB, Manjila S, Wu KC, Alwabili M, Abouammo MD, Manogaran RS, Lubbe DE, Carrau RL, Prevedello DM. Endoscopic precaruncular medial transorbital and endonasal multiport approaches to the contralateral skull base: a clinicoanatomical study. Neurosurg Focus 2024; 56:E10. [PMID: 38560943 DOI: 10.3171/2024.1.focus23863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/30/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Minimally invasive endoscopic endonasal multiport approaches create additional visualization angles to treat skull base pathologies. The sublabial contralateral transmaxillary (CTM) approach and superior eyelid lateral transorbital approach, frequently used nowadays, have been referred to as the "third port" when used alongside the endoscopic endonasal approach (EEA). The endoscopic precaruncular contralateral medial transorbital (cMTO) corridor, on the other hand, is an underrecognized but unique port that has been used to repair CSF rhinorrhea originating from the lateral sphenoid sinus recess. However, no anatomical feasibility studies or clinical experience exists to assess its benefits and demonstrate its potential role in multiport endoscopic access to the other contralateral skull base areas. In this study, the authors explored the application and potential utility of multiport EEA combined with the endoscopic cMTO approach (EEA/cMTO) to three target areas of the contralateral skull base: lateral recess of sphenoid sinus (LRSS), petrous apex (PA) and petroclival region, and retrocarotid clinoidocavernous space (CCS). METHODS Ten cadaveric specimens (20 sides) were dissected bilaterally under stereotactic navigation guidance to access contralateral LRSS via EEA/cMTO. The PA and petroclival region and retrocarotid CCS were exposed via EEA alone, EEA/cMTO, and EEA combined with the sublabial CTM approach (EEA/CTM). Qualitative and quantitative assessments, including working distance and visualization angle to the PA, were recorded. Clinical application of EEA/cMTO is demonstrated in a lateral sphenoid sinus CSF leak repair. RESULTS During the qualitative assessment, multiport EEA/cMTO provides superior visualization from a high vantage point and better instrument maneuverability than multiport EEA/CTM for the PA and retrocarotid CCS, while maintaining a similar lateral trajectory. The cMTO approach has significantly shorter working distances to all three target areas compared with the CTM approach and EEA. The mean distances to the LRSS, PA, and retrocarotid CCS were 50.69 ± 4.28 mm (p < 0.05), 67.11 ± 5.05 mm (p < 0.001), and 50.32 ± 3.6 mm (p < 0.001), respectively. The mean visualization angles to the PA obtained by multiport EEA/cMTO and EEA/CTM were 28.4° ± 3.27° and 24.42° ± 5.02° (p < 0.005), respectively. CONCLUSIONS Multiport EEA/cMTO to the contralateral LRSS offers the advantage of preserving the pterygopalatine fossa contents and the vidian nerve, which are frequently sacrificed during a transpterygoid approach. This approach also offers superior visualization and better instrument maneuverability compared with EEA/CTM for targeting the petroclival region and retrocarotid CCS.
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Affiliation(s)
- Govind S Bhuskute
- 1Department of ENT, All India Institute of Medical Sciences, Patna, Bihar, India
- 3Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University College of Medicine, Columbus, Ohio
| | - Jaskaran Singh Gosal
- Departments of2Neurological Surgery and
- 4Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Mohammad Bilal Alsavaf
- 3Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University College of Medicine, Columbus, Ohio
| | | | - Kyle C Wu
- Departments of2Neurological Surgery and
| | - Mohammed Alwabili
- 5Department of Otolaryngology-Head and Neck Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Moataz D Abouammo
- 3Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University College of Medicine, Columbus, Ohio
- 6Department of Otolaryngology-Head and Neck Surgery, Tanta University, Tanta, Egypt
| | - Ravi Sankar Manogaran
- 7Department of Neurosurgery, Neuro-Otology Unit, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India; and
| | - Darlene E Lubbe
- 8Division of Otolaryngology, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Ricardo L Carrau
- Departments of2Neurological Surgery and
- 3Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University College of Medicine, Columbus, Ohio
| | - Daniel M Prevedello
- Departments of2Neurological Surgery and
- 3Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University College of Medicine, Columbus, Ohio
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9
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Vignolles-Jeong J, Finger G, McGahan BG, Beaumont TL, Weber MD, Wu KC, Prevedello DM. Management of recurrent giant hemangiopericytoma: illustrative cases. J Neurosurg Case Lessons 2024; 7:CASE2432. [PMID: 38531083 DOI: 10.3171/case2432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/22/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Hemangiopericytoma (HPC) is a rare malignancy accounting for 0.4% of intracranial tumors. HPCs are characterized by local aggressiveness, high rates of recurrence, and a tendency to metastasize to extracranial sites. These features make management of HPCs challenging, often requiring a combination of radical resection and radiation. Given their rarity, optimal treatment algorithms remain undefined. OBSERVATIONS The authors report a series of four patients who underwent resection of intracranial HPC. Mean age at presentation was 49.3 years. Three patients had reoperation for progression of residual tumor, and one patient was surgically retreated for recurrence. One patient received adjuvant radiotherapy following initial resection, and three patients received adjuvant radiotherapy following resection of recurrent or residual disease. There was one death in the series. Average progression-free survival and overall survival following the index procedure were 32.8 and 82 months, respectively. Progression occurred locally in all patients, with metastatic recurrence in one patient. LESSONS The current gold-standard treatment for intracranial HPC consists of gross-total resection followed by radiation therapy. This approach allows satisfactory local control; however, given the tendency for these tumors to recur either locally or distally within or outside of the central nervous system, there is a need for salvage therapies to improve long-term outcomes for patients.
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Affiliation(s)
| | - Guilherme Finger
- 2Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ben G McGahan
- 2Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Thomas L Beaumont
- 3Department of Neurological Surgery, University of California, San Diego School of Medicine, San Diego, California; and
| | | | - Kyle C Wu
- 2Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio
- 4The James Cancer Hospital and Solove Research Institute, Columbus, Ohio
| | - Daniel M Prevedello
- 2Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio
- 4The James Cancer Hospital and Solove Research Institute, Columbus, Ohio
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Khaleghi M, Wu KC, Prevedello DM. Fully Endoscopic Minimally Invasive Trans-Eyebrow Supraorbital Translaminar Approach to Third Ventricle Craniopharyngiomas: Technical Nuances and Stepwise Illustrative Description. World Neurosurg 2024; 186:78-86. [PMID: 38522791 DOI: 10.1016/j.wneu.2024.03.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Traditional microsurgical approaches for addressing intraventricular craniopharyngioma provide limited access to the retrochiasmatic area and tumors with significant lateral or rostrocaudal extensions. Extended endoscopic endonasal approaches can effectively overcome many of limitations, yet they require a favorable working angle between the optic chiasm and pituitary gland, as well as the involvement of the third ventricle floor by the tumor. METHODS Herein, the authors describe the surgical nuances of a keyhole technique for resecting third ventricle craniopharyngiomas via a fully endoscopic minimally invasive trans-eyebrow supraorbital translaminar approach (ESOTLA). A case description detailing the key surgical steps and application of the approach is provided, along with a series of cadaveric photographs to highlight the relevant anatomy and step-by-step dissection process. RESULTS The patient is a 44-year-old man who presented with polyuria, low urine specific gravity, and panhypopituitarism. Brain magnetic resonance imaging revealed a solid-cystic heterogeneous-enhanced retrochiasmatic mass within the third ventricle, consistent with craniopharyngioma. A 1-stage ESOTLA was indicated based on the narrow pituitary-chiasm angle and the high functional status of the patient. Near-total resection was achieved, and no new postoperative neurologic or endocrine change was observed. Targeted therapy was implemented based on the histologic result, and the most recent surveillance magnetic resonance imaging showed no evidence of the residual tumor. CONCLUSIONS By combining a keyhole approach with variable-angle endoscopic visualization through a smaller bony and soft tissue exposure, ESOTLA can provide enhanced illumination within the third ventricle, potentially addressing cosmetic concerns and limited exposure area/angle of freedom associated with its conventional microsurgical counterpart.
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Affiliation(s)
- Mehdi Khaleghi
- Department of Neurosurgery, The James Cancer Center Hospital, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Kyle C Wu
- Department of Neurosurgery, The James Cancer Center Hospital, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, The James Cancer Center Hospital, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA.
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11
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Khaleghi M, Otto B, Carrau R, Abouammo MD, Prevedello DM. Customized ventral bony and dural opening in the transplanum/transtuberculum and transclival variants of extended endoscopic endonasal approach to suprasellar craniopharyngiomas: an approach-based stepwise cadaveric dissection and clinical applicability. Acta Neurochir (Wien) 2024; 166:146. [PMID: 38514521 DOI: 10.1007/s00701-024-06015-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/25/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Optimal initial exposure through an extended endoscopic endonasal approach (EEA) for suprasellar craniopharyngiomas ensures safe and unrestricted surgical access while avoiding overexposure, which may prolong the procedure and increase neurovascular adverse events. METHOD Here, the authors outline the surgical nuances of a customized bony and dural opening through the transplanum/transtuberculum and transclival variants of the extended EEA to suprasellar craniopharyngiomas based on the tumor-pituitary stalk relationship. A stepwise cadaveric dissection and intraoperative photographs relevant to the approaches are also provided. CONCLUSION Safe maximal resection of suprasellar craniopharyngiomas through extended EEAs can be feasibly and safely achieved by implementing of tailored ventral exposure.
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Affiliation(s)
- Mehdi Khaleghi
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Bradly Otto
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Ricardo Carrau
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Moataz D Abouammo
- Department of Otolaryngology-Head & Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
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Abouammo MD, Narayanan MS, Alsavaf MB, Alwabili M, Gosal JS, Bhuskute GS, Wu KC, Jawad BA, VanKoevering KK, Carrau RL, Prevedello DM. Contralateral Nasofrontal Trephination: A Novel Corridor for a "Dual Port" Approach to the Petrous Apex. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01097. [PMID: 38506519 DOI: 10.1227/ons.0000000000001119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/13/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Expanded endonasal approaches (EEAs) have proven safe and effective in treating select petrous apex (PA) pathologies. Angled endoscopes and instruments have expanded indications for such approaches; however, the complex neurovascular anatomy surrounding the petrous region remains a significant challenge. This study evaluates the feasibility, anatomic aspects, and limitations of a contralateral nasofrontal trephination (CNT) route as a complementary corridor improving access to the PA. METHODS Expanded endonasal and CNT approaches to the PA were carried out bilaterally in 15 cadaveric heads with endovascular latex injections. The distance to the PA, angle between instruments through the 2 approach portals, and surgical freedom were measured and compared. RESULTS Three-dimensional DICOM-based modeling and visualization indicate that the CNT route reduces the distance to the target located within the contralateral PA by an average of 3.33 cm (19%) and affords a significant increase in the angle between instruments (15.60°; 54%). Furthermore, the vertical vector of approach is improved by 28.97° yielding a caudal reach advantage of 2 cm. The area of surgical freedom afforded by 3 different approaches (endonasal, endonasal with an endoscope in CNT portal, and endonasal with an instrument in CNT portal) was compared at 4 points: the dural exit point of the 6th cranial nerve, jugular foramen, foramen lacerum, and petroclival fissure. The mean area of surgical freedom provided by both approaches incorporating the CNT corridor was superior to EEA alone at each of the surgical targets (P = <.001). CONCLUSION The addition of a CNT portal provides an additional avenue to expand on the classical EEA to the PA. This study provides insight into the anatomic nuances and potential clinical benefits of a dual-port approach to the PA.
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Affiliation(s)
- Moataz D Abouammo
- Department of Otorhinolaryngology-Head and Neck Surgery, Tanta University, Tanta, Egypt
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Maithrea S Narayanan
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Otolaryngology, Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia
| | - Mohammad Bilal Alsavaf
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, Ohio, USA
| | - Mohammed Alwabili
- Department of Otorhinolaryngology-Head and Neck Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Jaskaran Singh Gosal
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Govind S Bhuskute
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Otolaryngology, All India Institute of Medical Sciences (AIIMS), Patna, Bihar, India
| | - Kyle C Wu
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, Ohio, USA
| | - Basit A Jawad
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kyle K VanKoevering
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, Ohio, USA
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13
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Shah VS, Dornbos D, Hoang NA, Cua S, Rodgers B, Pezzutti D, Duenas H, Eaton R, Kreatsoulas D, Elder JB, Prevedello DM, Lonser RR, Nimjee SM. Preoperative prescription opioid use as an independent predictor of 90-day mortality and adverse events in craniotomy and craniectomy patients. J Neurosurg 2024:1-6. [PMID: 38457788 DOI: 10.3171/2024.1.jns23615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 01/04/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE A growing body of literature suggests that preoperative opioid exposure is an independent predictor of poor outcomes in surgical patients. No outcomes data exist on preoperative opioid use and craniotomies/craniectomies. The objective of this study was to determine the impact of preoperative opioid use on 90-day adverse events after craniotomy or craniectomy. METHODS A single-center retrospective cohort study of 2445 patients undergoing a craniotomy/craniectomy between January 1, 2013, and October 1, 2018, was conducted. Baseline demographics, pre- and postoperative opioid use (morphine milligram equivalents [MMEs]), and surgical metrics were recorded. Patients were categorized based on whether they took prescription opioids preoperatively, defined as within 1 month of surgery, or were opioid naive. The outcomes were mortality and adverse events 90 days after craniotomy/craniectomy. RESULTS Overall, 26.6% of patients composed the preoperative opioid group. The median daily MME intake among this group was 34.6 (IQR 14.1-90) MMEs. Lower employment rates (p < 0.001), uninsured status (p = 0.016), and intravenous drug use (p = 0.006) were associated with preoperative opioid use. Preoperative opioid use was associated with increased venous thromboembolism (p = 0.001), acute kidney injury (p = 0.002), acute respiratory failure (p < 0.001), myocardial infarction (p = 0.002), delirium (p < 0.001), and infection (p < 0.001). Preoperative opioid use was an independent predictor of overall 90-day adverse events (OR 1.643, 95% CI 1.289-2.095; p < 0.001) and 90-day mortality (OR 1.690, 95% CI 1.254-2.277; p < 0.001). CONCLUSIONS Preoperative opioid use was independently associated with 90-day postoperative adverse events and mortality. Opioid use increases vulnerability in craniotomy/craniectomy patients and necessitates close monitoring to improve outcomes.
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Affiliation(s)
- Varun S Shah
- 1College of Medicine, The Ohio State University, Columbus, Ohio
- 2Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - David Dornbos
- 3Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
- 4Department of Neurological Surgery, University of Tennessee Health Science Center and Semmes Murphey Clinic, Memphis, Tennessee
| | - Nguyen Alex Hoang
- 3Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - Santino Cua
- 1College of Medicine, The Ohio State University, Columbus, Ohio
| | - Brandon Rodgers
- 1College of Medicine, The Ohio State University, Columbus, Ohio
| | - Dante Pezzutti
- 1College of Medicine, The Ohio State University, Columbus, Ohio
| | - Helen Duenas
- 1College of Medicine, The Ohio State University, Columbus, Ohio
| | - Ryan Eaton
- 3Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - Daniel Kreatsoulas
- 3Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - J Bradley Elder
- 3Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - Daniel M Prevedello
- 3Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - Russell R Lonser
- 3Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - Shahid M Nimjee
- 3Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
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Damante MA, Magill ST, Kreatsoulas D, McGahan BG, Hardesty D, Carrau RL, Prevedello DM. Endoscopic Endonasal Transpterygoid Approach and the Need for Myringotomy. Laryngoscope 2024; 134:1203-1207. [PMID: 38087873 DOI: 10.1002/lary.31221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/06/2023] [Accepted: 11/21/2023] [Indexed: 02/17/2024]
Abstract
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.
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Affiliation(s)
- Mark A Damante
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, U.S.A
| | - Stephen T Magill
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Daniel Kreatsoulas
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, U.S.A
| | - Ben G McGahan
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, U.S.A
| | - Douglas Hardesty
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, U.S.A
| | - Ricardo L Carrau
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, U.S.A
- Department of Otolaryngology, The Ohio State University Medical Center, Columbus, Ohio, U.S.A
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, U.S.A
- Department of Otolaryngology, The Ohio State University Medical Center, Columbus, Ohio, U.S.A
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15
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Vignolles-Jeong J, Finger G, Magill ST, McGahan BG, Wu KC, Godil S, Prevedello DM. Supraorbital Eyebrow Approach for Translamina Terminalis Resection of Third Ventricle Metastasis: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01067. [PMID: 38376162 DOI: 10.1227/ons.0000000000001106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 01/08/2024] [Indexed: 02/21/2024] Open
Abstract
Tumors involving the third ventricle are rare, accounting for 0.6%-0.9% of all brain tumors. This deep-seated cavity is surrounded by critical neurovascular structures, making safe surgical resection of lesions in this region challenging. Traditionally, tumors of the third ventricle have been approached through a craniotomy and microsurgical resection.1-4 The supraorbital keyhole approach is a minimally invasive technique that can be used with minimal retraction of the brain and limited craniotomy while establishing a surgical field comparable with what can be achieved using traditional transcranial approaches. In this video, we describe the case of a 54-year-old man who underwent a supraorbital eyebrow approach for translamina terminalis resection of papillary thyroid carcinoma metastasis to the third ventricle. A gross total resection was achieved. The results achieved in our series are comparable with previously published reports of patients who underwent surgical resection of metastatic lesions involving the third ventricle.5-11 The patient consented to the procedure and to the publication of his image.
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Affiliation(s)
- Joshua Vignolles-Jeong
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Guilherme Finger
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Stephen T Magill
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois, USA
| | - Ben G McGahan
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Kyle C Wu
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Saniya Godil
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Candy NG, Wu KC, Finger G, VanKoevering K, Prevedello DM. Management of frontoethmoidal osteoma causing pneumocephalus and cerebrospinal fluid leakage with minimally invasive techniques: illustrative cases. J Neurosurg Case Lessons 2024; 7:CASE23699. [PMID: 38315987 PMCID: PMC10849144 DOI: 10.3171/case23699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/03/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Osteoid osteoma is a common benign bone tumor frequently seen in the frontoethmoid region. However, involvement of the skull base is rare, with few cases previously reported. OBSERVATIONS The authors report two cases of spontaneous, symptomatic frontoethmoidal osteoma: one presented with neurological deficit secondary to tension pneumocephalus and the other with cerebrospinal fluid leakage. The first case was managed with a transfrontal sinus craniotomy and pneumocephalus decompression with osteoma resection and skull base reconstruction. The second case was managed with a uninaral endoscopic endonasal approach to the anterior skull base with osteoma resection and reconstruction. LESSONS Given the paucity of cases with associated tension pneumocephalus described in the literature, it was relevant to describe the authors' experience with surgical decision-making and the expected outcomes among patients with this pathology when using minimally invasive techniques.
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Affiliation(s)
- Nicholas G Candy
- 1Department of Surgery-Otolaryngology, Head and Neck Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - Kyle C Wu
- 2Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio; and
| | - Guilherme Finger
- 2Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio; and
| | - Kyle VanKoevering
- 3Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Ohio
| | - Daniel M Prevedello
- 2Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio; and
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Zhang L, Kuo HC, Duhon BH, Adunka OF, Dodson EE, Hardesty DA, Prevedello DM, Otero JJ, Ren Y. Identifying Tumor Microenvironment Biomarkers in Adherent and Cystic Vestibular Schwannomas. Otol Neurotol 2024; 45:e113-e122. [PMID: 38082472 PMCID: PMC10843289 DOI: 10.1097/mao.0000000000004073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
OBJECTIVE A subset of vestibular schwannomas (VSs), including cystic tumors, have higher postoperative morbidity because of the presence of adhesions between the tumor, facial nerve (FN), and brainstem. We identify tumor microenvironment (TME) biomarkers to better classify these tumors and predict the degree of tumor adherence. STUDY DESIGN Retrospective case series. SETTING Tertiary skull base referral center. METHODS Adult patients with cystic and solid VS matched in tumor size who underwent surgical resection were included. Expressions of seven biomarkers of extracellular matrix remodeling and tumor immune response were quantified via immunohistochemistry. The distribution of CD45+ immune cells was evaluated in intratumoral and perivascular compartments. The degree of tumor adherence was categorized as none, adherent to FN, or adherent to both FN and brainstem. RESULTS Twenty-eight patients were included. Cystic VSs were significantly more adherent than solid VSs ( p = 0.02). Patients with adherent VS had shorter duration of symptoms and were more likely to undergo subtotal resection. In solid tumors, matrix metalloproteinase (MMP)-2 expression ( p = 0.02) and CD163+ macrophage infiltration ( p = 0.007) were correlated with tumor size. Linear discriminant analyses (LDAs) demonstrated MMP-2, MMP-14, CD80, CD163, and perivascular CD45 to be individually predictive of the degree of tumor adherence (all p < 0.05), with perivascular CD45 being the best independent predictor ( p = 0.005). An LDA model including these biomarkers demonstrated 100% accurate discrimination of all three levels of tumor adherence ( p = 0.04). CONCLUSIONS Adherent VS have a distinct proinflammatory TME characterized by elevated MMP expression, enrichment of tumor-associated macrophages, and perivascular immune cell infiltration.
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Affiliation(s)
- Lisa Zhang
- Division of Otology, Neurotology and Cranial Base Surgery, Department of Otolaryngology – Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hsuan-Chih Kuo
- Division of Otology, Neurotology and Cranial Base Surgery, Department of Otolaryngology – Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bailey H. Duhon
- Division of Otology, Neurotology and Cranial Base Surgery, Department of Otolaryngology – Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Oliver F. Adunka
- Division of Otology, Neurotology and Cranial Base Surgery, Department of Otolaryngology – Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Edward E. Dodson
- Division of Otology, Neurotology and Cranial Base Surgery, Department of Otolaryngology – Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Douglas A. Hardesty
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M. Prevedello
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jose J. Otero
- Division of Neuropathology, Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Yin Ren
- Division of Otology, Neurotology and Cranial Base Surgery, Department of Otolaryngology – Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Finger G, Ruiz MJC, Salem EH, Marquardt MD, Wu KC, Carlstrom LP, Carrau RL, Prevedello LM, Prevedello DM. The infundibulochiasmatic angle and the favorability of an endoscopic endonasal approach in type IV craniopharyngioma: illustrative case. J Neurosurg Case Lessons 2024; 7:CASE23545. [PMID: 38252928 PMCID: PMC10805591 DOI: 10.3171/case23545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/16/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Lesions located in the floor of the third ventricle are among the most difficult to access in neurosurgery. The neurovascular structures can limit transcranial exposure, whereas tumor extension into the third ventricle can limit visualization and access. The midline transsphenoidal route is an alternative approach to tumor invading the third ventricle if the tumor is localized at its anterior half and a working space between the optic apparatus and the pituitary infundibulum exists. The authors introduce the "infundibulochiasmatic angle," a valuable measurement supporting the feasibility of the translamina terminalis endoscopic endonasal approach (EEA) for resection of type IV craniopharyngiomas. OBSERVATIONS Due to a favorable infundibulochiasmatic angle measurement on preoperative magnetic resonance imaging (MRI), an endoscopic endonasal transsellar transtubercular approach was performed to resect a type IV craniopharyngioma. At 2-month follow-up, the patient's neurological exam was unremarkable, with improvement in bitemporal hemianopsia. Postoperative MRI confirmed gross-total tumor resection. LESSONS The infundibulochiasmatic angle is a radiological tool for evaluating the feasibility of EEA when resecting tumors in the anterior half of the third ventricle. Advantages include reduced brain retraction and excellent rates of resection, with minimal postoperative risks of cerebrospinal fluid leakage and permanent pituitary dysfunction.
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Affiliation(s)
- Guilherme Finger
- 1Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Maria Jose C Ruiz
- 2Department of Otolaryngology and Skull Base Surgery, Hospital Torrecardenas, Almeria, Spain
| | - Eman H Salem
- 3Department of Otolaryngology, Mansoura University, Mansoura, Egypt
| | | | - Kyle C Wu
- 1Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Lucas P Carlstrom
- 1Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ricardo L Carrau
- 5Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
| | - Luciano M Prevedello
- 6Department of Radiology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Daniel M Prevedello
- 1Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio
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Bhuskute GS, Gosal JS, Alsavaf MB, Abouammo MD, Manjila S, Kandregula S, Nayyar AK, Jha DK, Carrau RL, Prevedello DM. Morphometric Comparison of Endoscopic Endonasal Transpterygoid and Precaruncular Contralateral Medial Transorbital Approaches to Sphenoid Sinus Lateral Recess. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01021. [PMID: 38189446 DOI: 10.1227/ons.0000000000001053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/17/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The endoscopic endonasal transpterygoid approach (TPA), minimally invasive compared with the sublabial transmaxillary and transcranial approaches, still accounts for morbidity in benign lateral recess of sphenoid sinus (LRSS) pathologies. Others have suggested an alternative route to the LRSS, the endoscopic contralateral medial transorbital approach (cMTO). However, no quantitative evidence exists to support the clinical application of this approach. This cadaveric study, in a controlled laboratory setting, provides a morphometric comparison of the TPA and cMTO for accessing the LRSS. The study also details the anatomy and technical nuances for optimizing the cMTO corridor. METHODS Ten fresh preinjected human cadaveric specimens (20 sides) were dissected with neuronavigation, completing endoscopic cMTO and TPA on each side. Four parameters-working distance to lateral recess, surgical exposure area, angle of attack (AoA), and surgical freedom-were measured for each approach. Relevant osteological measurements in 10 dried human skulls were recorded. RESULTS The mean distance from the superior margin of the lacrimal sac impression to the inferior margin of the trochlear fossa was 10.29 ± 1.13 mm, and that from the anterior ethmoidal artery foramina to the posterior lacrimal crest was 9.63 ± 1.23 mm. The mean exposure area around the LRSS was significantly higher in TPA (614.09 ± 40.38 mm2) than in cMTO (391.19 ± 59.01 mm2, P = .001). The mean AoA was 9.83° and 10.24° in the cMTO and TPA, respectively, in the craniocaudal direction (P = .529). In the horizontal plane, it was 9.29° and 10.76° (P = .012). There was no significant difference in surgical freedom between the cMTO and TPA (804.61 and 806.05 mm3, respectively; P = .993). CONCLUSION Although comparatively limited exposure area, the cMTO approach has a similar AoA and surgical freedom as TPA and offers better visualization and ergonomic advantages. cMTO provides a feasible, less morbid, multiport technique for benign sphenoid sinus lateral recess pathologies.
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Affiliation(s)
- Govind S Bhuskute
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Jaskaran Singh Gosal
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
- Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Mohammad Bilal Alsavaf
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Moataz D Abouammo
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, Tanta University, Tanta, Egypt
| | - Sunil Manjila
- Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Sandeep Kandregula
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ashish K Nayyar
- Department of Anatomy, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Deepak K Jha
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Otolaryngology-Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
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Abouammo MD, Alsavaf MB, Prevedello DM, Ghalib L, Boyce AM, Carrau RL. RANK-L inhibitor as a promising agent for refractory extensive craniofacial fibrous dysplasia: A case report. Head Neck 2024; 46:E1-E5. [PMID: 37823398 PMCID: PMC10843282 DOI: 10.1002/hed.27546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 09/23/2023] [Accepted: 09/30/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND McCune-Albright syndrome is a rare disorder characterized by polyostotic fibrous dysplasia (FD), café-au-lait skin pigmentation, and endocrine dysfunction. Extensive FD in the craniofacial region can present significant challenges in terms of disease control and carries a high risk of permanent visual impairment. METHODS We present a case of medically and surgically resistant FD that required nine optic nerve decompressions. RESULTS The condition was ultimately controlled with the use of the denosumab agent. CONCLUSION The case highlights the importance and potential efficacy of denosumab in resistant FD management, particularly in cases involving sensitive organs.
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Affiliation(s)
- Moataz D. Abouammo
- Department of Otolaryngology - Head and Neck Surgery, Tanta University, Tanta, Egypt
- Department of Otolaryngology - Head and Neck Surgery, the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mohammad Bilal Alsavaf
- Department of Otolaryngology - Head and Neck Surgery, the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Neurological Surgery, the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M. Prevedello
- Department of Otolaryngology - Head and Neck Surgery, the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Neurological Surgery, the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Luma Ghalib
- Department of Endocrinology, Diabetes, and Metabolism, Wexner Medical Center, the Ohio State University, Columbus, Ohio, USA
| | - Alison M. Boyce
- Metabolic Bone Disorders Unit, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, USA
| | - Ricardo L. Carrau
- Department of Otolaryngology - Head and Neck Surgery, the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- Department of Neurological Surgery, the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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21
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Zhang L, Ostrander BT, Duhon B, Moshitaghi O, Lee J, Harris M, Hardesty DA, Prevedello DM, Schwartz MS, Dodson EE, Friedman RA, Adunka OF, Ren Y. Comparison of Postoperative Outcomes in Cystic Versus Solid Vestibular Schwannoma in a Multi-institutional Cohort. Otol Neurotol 2024; 45:92-99. [PMID: 38085765 PMCID: PMC10993235 DOI: 10.1097/mao.0000000000004062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVE Cystic vestibular schwannomas (cVSs) have more variable and less favorable clinical outcomes after microsurgical resection compared with solid VS (sVS). This study compares the preoperative presentation and postoperative outcomes between cVS and sVS. STUDY DESIGN Retrospective cohort study. SETTING Two tertiary skull base referral centers. METHODS Consecutive adult patients who underwent VS resection from 2016 to 2021 were included. Univariate and multivariate analyses compared differences in baseline symptoms and postoperative outcomes between cVS and sVS. RESULTS There were a total of 315 patients (64% female; mean age, 54 yrs) and 46 (15%) were cystic. cVS were significantly larger than sVS (maximum diameter, 28 vs. 18 mm, p < 0.001) and had higher rates of dysphagia and dysphonia preoperatively (p < 0.02). cVSs were more likely to undergo translabyrinthine resection (76 vs. 50%, p = 0.001) and have a higher rate of subtotal resection (STR) compared with sVS (30 vs. 13%, p = 0.003). At latest follow-up, fewer cVS achieved good facial nerve (FN) outcome (House-Brackmann [HB] I/II) (80 vs. 90%, p = 0.048). Subanalysis of cVS and sVS matched in tumor size, and surgical approach did not show differences in the rate of STR or FN outcomes (HB I/II, 82 vs. 78%, p = 0.79). CONCLUSION In this large multi-institutional series, cVSs represent a distinct entity and are characterized by larger tumor size and higher incidence of atypical symptoms. Although cVSs were more likely to undergo STR and portend worse FN outcomes than sVSs, this may be due to their larger tumor size rather than the presence of the cystic component.
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Affiliation(s)
- Lisa Zhang
- Division of Otology, Neurotology and Cranial Base Surgery, Department of Otolaryngology—Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Benjamin T. Ostrander
- Division of Otolaryngology—Head and Neck Surgery, Department of Otolaryngology, University of California, San Diego, La Jolla, California
| | - Bailey Duhon
- Division of Otology, Neurotology and Cranial Base Surgery, Department of Otolaryngology—Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Omid Moshitaghi
- Division of Otolaryngology—Head and Neck Surgery, Department of Otolaryngology, University of California, San Diego, La Jolla, California
| | - Joshua Lee
- Division of Otolaryngology—Head and Neck Surgery, Department of Otolaryngology, University of California, San Diego, La Jolla, California
| | - Micah Harris
- Department of Otolaryngology, University of Pittsburgh
| | - Douglas A. Hardesty
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Daniel M. Prevedello
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Marc S. Schwartz
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Edward E. Dodson
- Division of Otology, Neurotology and Cranial Base Surgery, Department of Otolaryngology—Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Rick A. Friedman
- Division of Otolaryngology—Head and Neck Surgery, Department of Otolaryngology, University of California, San Diego, La Jolla, California
| | - Oliver F. Adunka
- Division of Otology, Neurotology and Cranial Base Surgery, Department of Otolaryngology—Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Yin Ren
- Division of Otology, Neurotology and Cranial Base Surgery, Department of Otolaryngology—Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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22
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Pilonieta M, Pérez P, Prevedello DM. The Clinical Relevance of the Thalamogeniculate Arteries in Endoscopic Endonasal Surgery for Giant Pituitary Adenomas in the Interpeduncular Fossa. J Neurol Surg A Cent Eur Neurosurg 2024; 85:100-104. [PMID: 35760289 DOI: 10.1055/s-0042-1748773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Bilateral thalamic stroke is usually due to compromised artery of Percheron, an anatomical variation of the vascular supply of the thalamus. The stroke in this area is very uncommon, and is mainly due to top of the basilar syndrome. Other causes are extremely rare. We describe the case of a patient with a pituitary adenoma who underwent surgery and later presented with a bilateral thalamic infarct, suggesting compromise of the artery of Percheron. This would be the third case published in the literature about this complication. We present a literature review about the vascular supply of the thalamus, the artery of Percheron, and its involvement in pituitary surgery.
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Affiliation(s)
- Martin Pilonieta
- CALDAS, Santa Sofia de Caldas Academic State Hospital, Manizales, Colombia
| | - Paula Pérez
- CALDAS, Santa Sofia de Caldas Academic State Hospital, Manizales, Colombia
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University, Columbus, Ohio, United States
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23
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Almeida JP, Finger G, Weber MD, Damante MA, Wu KC, Walz P, Leonard JR, Carrau RL, Prevedello DM. Intradural Pituitary Hemitransposition: Technical Note and Case Series Illustration. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-01003. [PMID: 38132563 DOI: 10.1227/ons.0000000000001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/06/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Lesions located in the retrosellar region, interpeduncular cistern, and petroclival region are among the most difficult to access in neurosurgery. Transcranial approaches are useful; however, the large distance between the surgeon and the lesion as well as the presence of major neurovascular structures surrounding the lesion may limit surgical exposure. A midline transsphenoidal route avoids transgression of the neurovascular plane and provides direct access to the interpeduncular cistern. To safely access the interpeduncular fossa, it requires mobilization of the pituitary gland. The pituitary hemitransposition technique permits mobilization of the gland, while preserving its venous drainage and arterial supply to the gland on one of its sides, preserving gland function. The authors aim to describe the intradural pituitary hemitransposition technique and to demonstrate its safe application for resection of skull base tumors in the retrosellar space. METHODS The authors describe the surgical technique and illustrate its application in 5 cases of different types of skull base tumors, including a video demonstrating all the steps to perform this approach. In addition, the authors discuss the advantages and limitations of this technique compared with other approaches to the retrosellar space. RESULTS The intradural pituitary hemitransposition technique was used to safely resect a chondrosarcoma, chordoma, craniopharyngioma, teratoma, and meningioma involving the parasellar and retrosellar spaces, while minimizing endocrine morbidity. We had one patient with mild, albeit permanent hyperprolactinemia and hypothyroidism after surgery. No other patients had permanent dysfunction related to surgery. CONCLUSION The endonasal endoscopic intradural pituitary hemitransposition approach is an effective technique for resection of lesions located within the retrosellar and petroclival regions, allowing adequate exposure while potentially optimizing the preservation of the pituitary function.
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Affiliation(s)
- Joao Paulo Almeida
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Guilherme Finger
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthieu D Weber
- The Ohio State University College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Mark A Damante
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kyle C Wu
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Patrick Walz
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jeffrey R Leonard
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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24
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Alsavaf MB, Wu KC, Gosal JS, Finger G, Koch B, Abouammo MD, Prevedello LM, Carrau RL, Prevedello DM. Endoscopic endonasal marsupialization of rathke cleft cysts: clinical outcomes and risk factors analysis of visual impairment, pituitary dysfunction, and CSF leak. Pituitary 2023; 26:696-707. [PMID: 37878234 DOI: 10.1007/s11102-023-01347-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE This paper assesses the clinical and imaging characteristics, histopathological findings, and treatment outcomes of patients with Rathke's cleft cyst (RCC), as well as identifies potential risk factors for preoperative visual and pituitary dysfunction, intraoperative cerebrospinal fluid (CSF) leak, and recurrence. Through analyzing these factors, the study aims to contribute to the current understanding of the management of RCCs and identify opportunities for improving patient outcomes. METHODS We performed a retrospective analysis of 45 RCC patients between ages 18-80 treated by Endoscopic Endonasal Approach (EEA) and cyst marsupialization between 2010 and 2022 at a single institution. RESULTS The median patient age was 34, and 73% were female. The mean follow-up was 70 ± 43 months. Preoperative visual impairment correlated with cyst diameter (OR = 1.41, 95% CI = 1.07 to 1.85, p-value = 0.01) and older age (OR = 1.06, 95% CI = 1.01 to 1.11, p-value = 0.02). Intraoperative CSF leaks were 11 times more likely for cysts ≥ 2 cm (OR = 11.3, 95% CI = 1.25 to 97.37, p-value = 0.03), with the odds of leakage doubling for every 0.1 cm increase in cyst size (OR = 1.41, 95% CI = 1.08 to 1.84, p-value = 0.01). Preoperative RCC appearing hypointense on T1 images demonstrated significantly higher CSF leak rates than hyperintense lesions (OR = 122.88, 95% CI = 1.5 to 10077.54, p-value = 0.03). Preoperative pituitary hypofunction was significantly more likely in patients with the presence of inflammation on histopathology (OR = 20.53, 95% CI = 2.20 to 191.45, p-value = 0.008 ) and T2 hyperintensity on magnetic resonance imaging (MRI) sequences (OR = 23.2, 95% CI = 2.56 to 211.02, p-value = 0.005). Notably, except for the hyperprolactinemia, no postoperative improvement was observed in pituitary function. CONCLUSION Carefully considering risk factors, surgeons can appropriately counsel patients and deliver expectations for complications and long-term results. In contrast to preoperative visual impairment, preoperative pituitary dysfunction was found to have the least improvement post-surgery. It was the most significant permanent complication, with our data indicating the link to the cyst signal intensity on T2 MR and inflammation on histopathology. Earlier surgical intervention might improve the preservation of pituitary function.
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Affiliation(s)
- Mohammad Bilal Alsavaf
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave Columbus Ohio, Columbus, OH, USA
| | - Kyle C Wu
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave Columbus Ohio, Columbus, OH, USA
- The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA
| | - Jaskaran S Gosal
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Jodhpur, 342005, Rajasthan, India
| | - Guilherme Finger
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave Columbus Ohio, Columbus, OH, USA
| | - Brandon Koch
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Moataz D Abouammo
- Department of Otolaryngology - Head and Neck Surgery, Tanta University, Tanta, Egypt
| | - Luciano M Prevedello
- The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA
- Department of Neuroradiology, Wexner Medical Center at The Ohio State University, Columbus, OH, USA
| | - Ricardo L Carrau
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave Columbus Ohio, Columbus, OH, USA
- The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA
| | - Daniel M Prevedello
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave Columbus Ohio, Columbus, OH, USA.
- The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA.
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25
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Magill ST, Schwartz TH, Couldwell WT, Gardner PA, Heilman CB, Sen C, Akagami R, Cappabianca P, Prevedello DM, McDermott MW. International Tuberculum Sellae Meningioma Study: Surgical Outcomes and Management Trends. Neurosurgery 2023; 93:1259-1270. [PMID: 37389475 DOI: 10.1227/neu.0000000000002569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/25/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Tuberculum sellae meningiomas (TSMs) can be resected through transcranial (TCA) or expanded endonasal approach (EEA). The objective of this study was to report TSM management trends and outcomes in a large multicenter cohort. METHODS This is a 40-site retrospective study using standard statistical methods. RESULTS In 947 cases, TCA was used 66.4% and EEA 33.6%. The median maximum diameter was 2.5 cm for TCA and 2.1 cm for EEA ( P < .0001). The median follow-up was 26 months. Gross total resection (GTR) was achieved in 70.2% and did not differ between EEA and TCA ( P = .5395). Vision was the same or better in 87.5%. Vision improved in 73.0% of EEA patients with preoperative visual deficits compared with 57.1% of TCA patients ( P < .0001). On multivariate analysis, a TCA (odds ratio [OR] 1.78, P = .0258) was associated with vision worsening, while GTR was protective (OR 0.37, P < .0001). GTR decreased with increased diameter (OR: 0.80 per cm, P = .0036) and preoperative visual deficits (OR 0.56, P = .0075). Mortality was 0.5%. Complications occurred in 23.9%. New unilateral or bilateral blindness occurred in 3.3% and 0.4%, respectively. The cerebrospinal fluid leak rate was 17.3% for EEA and 2.2% for TCA (OR 9.1, P < .0001). The recurrence rate was 10.9% (n = 103). Longer follow-up (OR 1.01 per month, P < .0001), World Health Organization II/III (OR 2.20, P = .0262), and GTR (OR: 0.33, P < .0001) were associated with recurrence. The recurrence rate after GTR was lower after EEA compared with TCA (OR 0.33, P = .0027). CONCLUSION EEA for appropriately selected TSM may lead to better visual outcomes and decreased recurrence rates after GTR, but cerebrospinal fluid leak rates are high, and longer follow-up is needed. Tumors were smaller in the EEA group, and follow-up was shorter, reflecting selection, and observation bias. Nevertheless, EEA may be superior to TCA for appropriately selected TSM.
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Affiliation(s)
- Stephen T Magill
- Department of Neurological Surgery, Northwestern University, Chicago , Illinois , USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco , California , USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Cornell University, New York , New York , USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Carl B Heilman
- Department of Neurological Surgery, Tufts University, Boston , Massachusetts , USA
| | - Chandranath Sen
- Department of Neurological Surgery, New York University, New York , New York , USA
| | - Ryojo Akagami
- Department of Neurological Surgery, University of British Columbia, Vancouver , British Columbia , Canada
| | - Paolo Cappabianca
- Department of Neurological Surgery, Universita degli Studi di Napoli Federico II, Naples , Italy
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University, Columbus , Ohio , USA
| | - Michael W McDermott
- Miami Neuroscience Institute, Baptist Health South Florida, Miami , Florida , USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco , California , USA
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26
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Zandbergen IM, Huntoon KM, White TG, Bakker LEH, Verstegen MJT, Ghalib LM, van Furth WR, Pelsma ICM, Dehdashti AR, Biermasz NR, Prevedello DM. Efficacy and Safety of Endoscopic Transsphenoidal Resection for Prolactinoma: A Retrospective Multicenter Case-series. Arch Med Res 2023; 54:102919. [PMID: 38040527 DOI: 10.1016/j.arcmed.2023.102919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/03/2023] [Accepted: 11/13/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Endoscopic transsphenoidal surgery (ETSS) for prolactinoma is reserved for dopamine agonist (DA) resistance, intolerance, or apoplexy. High remission (overall 67%, microprolactinoma up to 90%), low recurrence (5-20%) rates highlighted that surgery might be first-line treatment. AIMS To report on outcomes of ETSS in a cohort of prolactinomas. METHODS Multicenter retrospective cohort of 137 prolactinoma patients (age 38.2 ± 13.7 years; 61.3% female, median follow-up 28.0 [15.0-55.5] months) operated between 2010-2019 with histopathological confirmation. RESULTS Median preoperative prolactin levels were 166 (98-837 µg/L; males 996 [159-2145 µg/L] vs. females 129 [84-223 µg/L], p <0.001). 56 (40.9%) microprolactinomas, 69 (50.4%) macroprolactinomas, and 7 (5.1%) giant prolactinomas were included, whereas no adenoma was detected in 5 (3.6%) patients. Males had larger tumors (macroprolactinomas: 38, 71.7%) vs. 31 (36.9%), p <0.001; giant prolactinomas: 7 (13.2%) vs. 0 (0.0%), (p <0.001). Prolactinomas were graded as KNOSP-3 in 15 (11.5%), and KNOSP-4 in 20 (15.3%) patients. Primary indication was DA intolerance (59, 43.1%); males 14 (26.4%) vs. females 45 (53.6%), p = 0.006. Long-term remission (i.e., DA-free prolactin level <1xULN) was achieved in 87 (63.5%) patients, being higher in intended complete resection (69/92 [75.0%]), and lower in males (25 [47.2%] vs. 62 females [73.8%], p = 0.002). Transient DI (n = 29, 21.2%) was the most frequent complication. CONCLUSIONS Despite high proportions of macroprolactinoma and KNOSP 3-4, long-term remission rates were 63.5% overall, and 83.3% in microprolactinoma patients. Males had less favorable remission rate compared to females. These findings highlight that ETSS may be a safe and efficacious treatment to manage prolactinoma.
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Affiliation(s)
- Ingrid Marijke Zandbergen
- Department of Neurosurgery, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands; Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands.
| | | | - Timothy G White
- Department of Neurosurgery, Hofstra University Northwell Health, Long Island, NY, USA
| | - Leontine Erica Henriëtte Bakker
- Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Luma Mudhafar Ghalib
- Department of Endocrinology, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Wouter Ralph van Furth
- Department of Neurosurgery, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Iris Catharina Maria Pelsma
- Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Amir R Dehdashti
- Department of Neurosurgery, Hofstra University Northwell Health, Long Island, NY, USA
| | - Nienke Ruurdje Biermasz
- Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH USA
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Magill ST, Schwartz TH, Couldwell WT, Gardner PA, Heilman CB, Sen C, Akagami R, Cappabianca P, Prevedello DM, McDermott MW. International Tuberculum Sellae Meningioma Study: Preoperative Grading Scale to Predict Outcomes and Propensity-Matched Outcomes by Endonasal Versus Transcranial Approach. Neurosurgery 2023; 93:1271-1284. [PMID: 37418417 DOI: 10.1227/neu.0000000000002581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/26/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Tuberculum sellae meningiomas are resected via an expanded endonasal (EEA) or transcranial approach (TCA). Which approach provides superior outcomes is debated. The Magill-McDermott (M-M) grading scale evaluating tumor size, optic canal invasion, and arterial involvement remains to be validated for outcome prediction. The objective of this study was to validate the M-M scale for predicting visual outcome, extent of resection (EOR), and recurrence, and to use propensity matching by M-M scale to determine whether visual outcome, EOR, or recurrence differ between EEA and TCA. METHODS Forty-site retrospective study of 947 patients undergoing tuberculum sellae meningiomas resection. Standard statistical methods and propensity matching were used. RESULTS The M-M scale predicted visual worsening (odds ratio [OR]/point: 1.22, 95% CI: 1.02-1.46, P = .0271) and gross total resection (GTR) (OR/point: 0.71, 95% CI: 0.62-0.81, P < .0001), but not recurrence ( P = .4695). The scale was simplified and validated in an independent cohort for predicting visual worsening (OR/point: 2.34, 95% CI: 1.33-4.14, P = .0032) and GTR (OR/point: 0.73, 95% CI: 0.57-0.93, P = .0127), but not recurrence ( P = .2572). In propensity-matched samples, there was no difference in visual worsening ( P = .8757) or recurrence ( P = .5678) between TCA and EEA, but GTR was more likely with TCA (OR: 1.49, 95% CI: 1.02-2.18, P = .0409). Matched patients with preoperative visual deficits who had an EEA were more likely to have visual improvement than those undergoing TCA (72.9% vs 58.4%, P = .0010) with equal rates of visual worsening (EEA 8.0% vs TCA 8.6%, P = .8018). CONCLUSION The refined M-M scale predicts visual worsening and EOR preoperatively. Preoperative visual deficits are more likely to improve after EEA; however, individual tumor features must be considered during nuanced approach selection by experienced neurosurgeons.
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Affiliation(s)
- Stephen T Magill
- Department of Neurological Surgery, Northwestern University, Chicago , Illinois , USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco , California , USA
| | - Theodore H Schwartz
- Department of Neurological Surgery, Cornell University, New York , New York , USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Carl B Heilman
- Department of Neurological Surgery, Tufts University, Boston , Massachusetts , USA
| | - Chandranath Sen
- Department of Neurological Surgery, New York University, New York , New York , USA
| | - Ryojo Akagami
- Department of Neurological Surgery, University of British Columbia, Vancouver , British Columbia , Canada
| | - Paolo Cappabianca
- Department of Neurological Surgery, Universita degli Studi di Napoli Federico II, Naples , Italy
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University, Columbus , Ohio , USA
| | - Michael W McDermott
- Miami Neuroscience Institute, Baptist Health South Florida, Miami , Florida , USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco , California , USA
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Finger G, Gun R, Wu KC, Carrau RL, Prevedello DM. Endoscopic Endonasal Transpterygoid Approach: Technical Lessons. Oper Neurosurg (Hagerstown) 2023; 25:e272. [PMID: 37350591 DOI: 10.1227/ons.0000000000000738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/03/2023] [Indexed: 06/24/2023] Open
Abstract
INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE The endoscopic endonasal transpterygoid approach (EETPA) provides direct access to the petrous apex, lateral clivus, inferior cavernous sinus compartment, jugular foramen, and infratemporal fossa. 1,2 In the coronal plane, it provides exposure far beyond a traditional sphenoidotomy. ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT The pterygoid process of the sphenoid bone forms the junction between the body and greater sphenoid wing before bifurcating because it descends into medial and lateral plates. The key to this exposure lies in the region's bony foramina: the palatovaginal canal, vidian canal, and foramen rotundum. 3. ESSENTIALS STEPS OF THE PROCEDURE After performing a maxillary antrostomy, stepwise exposure of these foramina leads to the pterygopalatine fossa. The sphenopalatine artery is cauterized as it becomes the posterior septal artery at the sphenopalatine foramen, and the maxillary sinus' posterior wall is opened to expose the pterygopalatine fossa. After mobilizing and retracting the contents of the pterygopalatine fossa, the pterygoid process is removed, improving access in the coronal plane. 4. PITFALLS/AVOIDANCE OF COMPLICATIONS Vidian neurectomy causes decreased or absent lacrimation. Injury to the maxillary nerve or its branches results in facial, palatal, or odontogenic anesthesia or neuralgia. In addition, the EEPTA precludes the ability to raise an ipsilateral nasal septal flap, making it crucial to plan reconstruction preoperatively. 4,5. VARIANTS AND INDICATIONS FOR THEIR USE There are 5 variants of the EEPTA: extended pterygopalatine fossa, lateral recess of the sphenoid sinus, petrous apex, infratemporal fossa and petrous carotid artery, and middle and posterior skull base. 5The patient consented to the procedure.Images in the video used with permission as follows: images at 0:33 and 1:15 reused from Bozkurt et al, 3 © Georg Thieme Verlag KG; image at 0:39 from Prosser et al, 5 © John Wiley and Sons; images at 0:54, 9:03, and 9:38 from Kasemsiri et al, 1 © John Wiley and Sons; images at 1:07 and 9:44 from Falcon et al, 2 © John Wiley and Sons; image at 1:15 from Sandu et al, 4 © Springer Nature.
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Affiliation(s)
- Guilherme Finger
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Ramazan Gun
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kyle C Wu
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Finger G, Kaul VF, Adunka OF, Prevedello DM. Subfascial dissection and extended temporal muscle detachment for middle fossa approach. Acta Neurochir (Wien) 2023; 165:3473-3477. [PMID: 36625906 DOI: 10.1007/s00701-022-05483-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/27/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND The soft tissue dissection for the middle fossa approach requires adequate management of the neuro, vascular, and muscular structures in order to maximize exposure and diminish morbidities. METHODS An incision anterior to the tragus is performed, extending from the zygomatic process to the superior temporal line. The superior temporal artery is exposed, followed by a subfascial dissection of the frontalis nerve. The temporal muscle is dissected and released from the zygoma. All cranial landmarks are exposed for the 5 × 5 cm temporal fossa craniotomy. CONCLUSION This novel approach provides a safe and adequate access to perform an extended middle fossa craniotomy.
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Affiliation(s)
- Guilherme Finger
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Doan Hall N 1049, 460 W 10Th Ave, Columbus, OH, 43210, USA.
| | - Vivian F Kaul
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Oliver F Adunka
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Doan Hall N 1049, 460 W 10Th Ave, Columbus, OH, 43210, USA
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Sheehan J, Yang I, Prevedello DM. Stereotactic radiosurgery for large vestibular schwannomas: 2.5 cm and beyond. J Neurooncol 2023; 165:381-383. [PMID: 37976031 DOI: 10.1007/s11060-023-04502-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/04/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Jason Sheehan
- Department of Neurosurgery, University of Virginia, Box 800212, Charlottesville, VA 22908, USA.
| | - Isaac Yang
- Neurosurgery, Radiation Oncology, Head and Neck Surgery, Jonsson Comprehensive Cancer Center, Harbor-UCLA Medical Center, David Geffen School of Medicine, Los Angeles (UCLA), Los Angeles, USA
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Finger G, Wu KC, Vignolles-Jeong J, Godil SS, McGahan BG, Kreatsoulas D, Shujaat MT, Prevedello LM, Prevedello DM. A New Finding on Magnetic Resonance Imaging for Diagnosis of Hemifacial Spasm with High Accuracy and Interobserver Correlation. Brain Sci 2023; 13:1434. [PMID: 37891802 PMCID: PMC10605702 DOI: 10.3390/brainsci13101434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/27/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023] Open
Abstract
Among patients with clinical hemifacial spasm (HFS), imaging exams aim to identify the neurovascular conflict (NVC) location. It has been proven that the identification in the preoperative exam increases the rate of surgical success. Despite the description of specific magnetic resonance image (MRI) acquisitions, the site of neurovascular compression is not always visualized. The authors describe a new MRI finding that helps in the diagnosis of HFS, and evaluate the sensitivity, specificity, and interobserver correlation of the described sign. A cross-sectional study including cases of hemifacial spasm treated surgically from 1 August 2011 to 31 July 2021 was performed. The MRIs of the cases were independently evaluated by two experienced neuroradiologists, who were blinded regarding the side of the symptom. The neuroradiologists were assigned to evaluate the MRIs in two separate moments. Primarily, they evaluated whether there was a neurovascular conflict based on the standard technique. Following this initial analysis, the neuroradiologists received a file with the description of the novel sign, named Prevedello Sign (PS). In a second moment, the same neuroradiologists were asked to identify the presence of the PS and, if it was present, to report on which side. A total of 35 patients were included, mostly females (65.7%) with a mean age of 59.02 (+0.48). Since the 35 cases were independently evaluated by two neuroradiologists, a total of 70 reports were included in the analysis. The PS was present in 66 patients (sensitivity of 94.2%, specificity of 91.4% and positive predictive value of 90.9%). When both analyses were performed in parallel (standard plus PS), the sensitivity increased to 99.2%. Based on the findings of this study, the authors conclude that PS is helpful in determining the neurovascular conflict location in patients with HFS. Its presence, combined with the standard evaluation, increases the sensitivity of the MRI to over 99%, without increasing risks of harm to patients or resulting in additional costs.
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Affiliation(s)
- Guilherme Finger
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH 43210, USA; (G.F.); (K.C.W.); (D.K.)
| | - Kyle C. Wu
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH 43210, USA; (G.F.); (K.C.W.); (D.K.)
| | - Joshua Vignolles-Jeong
- College of Medicine, The Ohio State University College of Medicine, Columbus, OH 43210, USA;
| | - Saniya S. Godil
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH 43210, USA; (G.F.); (K.C.W.); (D.K.)
| | - Ben G. McGahan
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH 43210, USA; (G.F.); (K.C.W.); (D.K.)
| | - Daniel Kreatsoulas
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH 43210, USA; (G.F.); (K.C.W.); (D.K.)
| | - Mohammad T. Shujaat
- Department of Radiology, The Ohio State University College of Medicine, Columbus, OH 43210, USA (L.M.P.)
| | - Luciano M. Prevedello
- Department of Radiology, The Ohio State University College of Medicine, Columbus, OH 43210, USA (L.M.P.)
| | - Daniel M. Prevedello
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH 43210, USA; (G.F.); (K.C.W.); (D.K.)
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Weber MD, Finger G, Munjal V, Wu KC, Jawad B, Akhter AS, Chakravarthy VB, Carrau RL, Prevedello DM. Real-time ultrasound guidance in the endoscopic endonasal resection of a retro-odontoid pannus: Technical note and case illustration. J Craniovertebr Junction Spine 2023; 14:433-437. [PMID: 38268692 PMCID: PMC10805169 DOI: 10.4103/jcvjs.jcvjs_117_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 10/16/2023] [Indexed: 01/26/2024] Open
Abstract
Background and Objectives Odontoidectomy is a surgical procedure indicated in the setting of various pathologies, with the main goal of decompressing the ventral brain stem and spinal cord as a result of irreducible compression at the craniovertebral junction. The endoscopic endonasal approach has been increasingly used as an alternative to the transoral approach as it provides a straightforward, panoramic, and direct approach to the odontoid process. In addition, intraoperative ultrasound (US) guidance is a technique that can optimize safety and surgical outcomes in this context. It is used as an adjunct to neuronavigation and provides intraoperative confirmation of decompression of craniovertebral junction structures in real time. The authors aim to present the use and safe application of real-time intraoperative US guidance during endonasal endoscopic resection of a retro-odontoid pannus. Methods A retrospective chart review of a single case was performed and presented herein as a case report and narrated operative video. Results A minimally invasive US transducer was used intraoperatively to guide the resection of a retro-odontoid pannus and confirm spinal cord decompression in real time. Postoperative examination of the patient revealed immediate neurological improvement. Conclusions Intraoperative ultrasonography is a well described and useful modality in neurosurgery. However, the use of intraoperative US guidance during endonasal endoscopic approaches to the craniovertebral junction has not been previously described. As demonstrated in this technical note, the authors show that this imaging modality can be added to the ever-evolving armamentarium of neurosurgeons to safely guide the decompression of neural structures within the craniocervical junction with good surgical outcomes.
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Affiliation(s)
| | - Guilherme Finger
- The Ohio State University Wexner Medical Center, Department of Neurosurgery, Columbus, OH, USA
| | - Vikas Munjal
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kyle C. Wu
- The Ohio State University Wexner Medical Center, Department of Neurosurgery, Columbus, OH, USA
| | - Basit Jawad
- The Ohio State University Wexner Medical Center, Department of Otolaryngology - Head and Neck Surgery, Columbus, OH, USA
| | - Asad S. Akhter
- The Ohio State University Wexner Medical Center, Department of Neurosurgery, Columbus, OH, USA
| | - Vikram B. Chakravarthy
- The Ohio State University Wexner Medical Center, Department of Neurosurgery, Columbus, OH, USA
| | - Ricardo L. Carrau
- The Ohio State University Wexner Medical Center, Department of Otolaryngology - Head and Neck Surgery, Columbus, OH, USA
| | - Daniel M. Prevedello
- The Ohio State University Wexner Medical Center, Department of Neurosurgery, Columbus, OH, USA
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Labib MA, Abramov I, Houlihan LM, Srinivasan VM, Scherschinski L, Prevedello DM, Carrau RL, Abou-Al-Shaar H, Preul MC, Lawton MT. Combined subtarsal contralateral transmaxillary retroeustachian and endoscopic endonasal approaches to the infrapetrous region. J Neurosurg 2023; 139:992-1001. [PMID: 37566787 DOI: 10.3171/2023.1.jns221854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/20/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE The eustachian tube (ET) limits endoscopic endonasal access to the infrapetrous region. Transecting or mobilizing the ET may result in morbidities. This study presents a novel approach in which a subtarsal contralateral transmaxillary (ST-CTM) corridor is coupled with the standard endonasal approach to facilitate access behind the intact ET. METHODS Eight cadaveric head specimens were dissected. Endoscopic endonasal approaches (EEAs) (i.e., transpterygoid and inferior transclival) were performed on one side, followed by ST-CTM and sublabial contralateral transmaxillary (SL-CTM) approaches on the opposite side, along with different ET mobilization techniques on the original side. Seven comparative groups were generated. The length of the cranial nerves, areas of exposure, and volume of surgical freedom (VSF) in the infrapetrous regions were measured and compared. RESULTS Without ET mobilization, the combined ST-CTM/EEA approach provided greater exposure than EEA alone (mean ± SD 288.9 ± 40.66 mm2 vs 91.7 ± 49.9 mm2; p = 0.001). The VSFs at the ventral jugular foramen (JF), entrance to the petrous internal carotid artery (ICA), and lateral to the parapharyngeal ICA were also greater in ST-CTM/EEA than in EEA alone (p = 0.002, p = 0.002, and p < 0.001, respectively). EEA alone, however, provided greater VSF at the hypoglossal canal (HGC) than did ST-CTM/EEA (p = 0.01). The SL-CTM approach did not increase the EEA exposure (p = 0.48). The ST-CTM/EEA approach provided greater exposure than EEA with extended inferolateral (EIL) or anterolateral (AL) ET mobilization (p = 0.001 and p = 0.02, respectively). The ST-CTM/EEA also increased the VSF lateral to the parapharyngeal ICA in comparison with EEA/EIL ET mobilization (p < 0.001) but not with EEA/AL ET mobilization (p = 0.36). Finally, the VSFs at the HGC and JF were greater in EEA/AL ET mobilization than in ST-CTM/EEA without ET mobilization (p = 0.002 and p = 0.004, respectively). CONCLUSIONS Combining the EEA with the more laterally and superiorly originating ST-CTM approach allows greater exposure of the infrapetrous and ventral JF regions while obviating the need for mobilizing the ET. The surgical freedom afforded by the combined approaches is greater than that obtained by EEA alone.
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Affiliation(s)
- Mohamed A Labib
- 1Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Irakliy Abramov
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Lena Mary Houlihan
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Visish M Srinivasan
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Lea Scherschinski
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Daniel M Prevedello
- Departments of3Neurosurgery and
- 4Otolaryngology, Ohio State University, Columbus, Ohio; and
| | - Ricardo L Carrau
- Departments of3Neurosurgery and
- 4Otolaryngology, Ohio State University, Columbus, Ohio; and
| | | | - Mark C Preul
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- 2Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Alsavaf MB, Salem EH, Jawad BA, Mongkolkul K, Carrau RL, Prevedello DM. A rare case of multifocal chordoma involving the lower clivus and multiple spine levels: illustrative case. J Neurosurg Case Lessons 2023; 6:CASE23177. [PMID: 37728313 PMCID: PMC10555553 DOI: 10.3171/case23177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/22/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Chordomas are rare bone tumors originating from notochord remnants with a predilection for the median axis of the body, primarily in the sacrococcygeal spine, skull base, and cervical spine. This paper presents the first reported case of simultaneous multilevel chordomas with various enhancements. OBSERVATIONS A 40-year-old woman presented with right-sided otalgia, headache, nasal obstruction, and facial pressure. The patient's head and spinal magnetic resonance imaging (MRI) demonstrated a midline lesion in the clivus, C2, and T1-5 spinal levels. All lesions were T1 isointense and T2 hyperintense, consistent with chordoma. Interestingly, the clivus lesion was enhancing, whereas the C2 lesion was only slightly enhancing, and the rest of the lesions showed no enhancement. The patient underwent endoscopic endonasal transclival approach surgery for the clival lesion, followed by radiation to the surgical bed and the C2 lesion. The remaining lesions were monitored. Follow-up imaging showed stable disease in the C2 lesion and other lower lesions. The patient's severe pain in the posterior cervical spine was managed with cervical fusion, pain management, and physical therapy. LESSONS This case underscores the importance of comprehensive spinal MRI in patients with chordomas, as multiple concurrent primaries may be present. The article summarizes the fundamental distinctions between ecchordosis physaliphora and chordoma and casts doubt on the capacity to always differentiate them.
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Affiliation(s)
- Mohammad Bilal Alsavaf
- Departments of1Otolaryngology-Head and Neck Surgery and
- 2Neurological Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Eman H Salem
- 3Department of Otolaryngology, Faculty of Medicine, Mansoura University, Mansoura, Egypt; and
| | - Basit A Jawad
- Departments of1Otolaryngology-Head and Neck Surgery and
| | - Kittichai Mongkolkul
- 4Department of Otolaryngology-Head and Neck Surgery, Rajavithi Hospital, The College of Medicine of Rangsit University, Bangkok, Thailand
| | - Ricardo L Carrau
- Departments of1Otolaryngology-Head and Neck Surgery and
- 2Neurological Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Daniel M Prevedello
- Departments of1Otolaryngology-Head and Neck Surgery and
- 2Neurological Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
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Tangsrivimol JA, Schonfeld E, Zhang M, Veeravagu A, Smith TR, Härtl R, Lawton MT, El-Sherbini AH, Prevedello DM, Glicksberg BS, Krittanawong C. Artificial Intelligence in Neurosurgery: A State-of-the-Art Review from Past to Future. Diagnostics (Basel) 2023; 13:2429. [PMID: 37510174 PMCID: PMC10378231 DOI: 10.3390/diagnostics13142429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
In recent years, there has been a significant surge in discussions surrounding artificial intelligence (AI), along with a corresponding increase in its practical applications in various facets of everyday life, including the medical industry. Notably, even in the highly specialized realm of neurosurgery, AI has been utilized for differential diagnosis, pre-operative evaluation, and improving surgical precision. Many of these applications have begun to mitigate risks of intraoperative and postoperative complications and post-operative care. This article aims to present an overview of the principal published papers on the significant themes of tumor, spine, epilepsy, and vascular issues, wherein AI has been applied to assess its potential applications within neurosurgery. The method involved identifying high-cited seminal papers using PubMed and Google Scholar, conducting a comprehensive review of various study types, and summarizing machine learning applications to enhance understanding among clinicians for future utilization. Recent studies demonstrate that machine learning (ML) holds significant potential in neuro-oncological care, spine surgery, epilepsy management, and other neurosurgical applications. ML techniques have proven effective in tumor identification, surgical outcomes prediction, seizure outcome prediction, aneurysm prediction, and more, highlighting its broad impact and potential in improving patient management and outcomes in neurosurgery. This review will encompass the current state of research, as well as predictions for the future of AI within neurosurgery.
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Affiliation(s)
- Jonathan A Tangsrivimol
- Division of Neurosurgery, Department of Surgery, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok 10210, Thailand
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and Jame Cancer Institute, Columbus, OH 43210, USA
| | - Ethan Schonfeld
- Department Biomedical Informatics, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Michael Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Anand Veeravagu
- Stanford Neurosurgical Artificial Intelligence and Machine Learning Laboratory, Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Timothy R Smith
- Department of Neurosurgery, Computational Neuroscience Outcomes Center (CNOC), Mass General Brigham, Harvard Medical School, Boston, MA 02115, USA
| | - Roger Härtl
- Weill Cornell Medicine Brain and Spine Center, New York, NY 10022, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute (BNI), Phoenix, AZ 85013, USA
| | - Adham H El-Sherbini
- Faculty of Health Sciences, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center and Jame Cancer Institute, Columbus, OH 43210, USA
| | - Benjamin S Glicksberg
- Hasso Plattner Institute for Digital Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Chayakrit Krittanawong
- Cardiology Division, New York University Langone Health, New York University School of Medicine, New York, NY 10016, USA
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Finger G, Wu KC, Gosal JS, Jawad B, Vignolles-Jeong J, Carrau RL, Prevedello DM. Endoscopic ultrasound guided resection of a Cushing's adenoma invading the medial cavernous sinus wall using the "interdural peeling" technique. Neurosurg Focus Video 2023; 9:V4. [PMID: 37416807 PMCID: PMC10321548 DOI: 10.3171/2023.4.focvid22150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 04/14/2023] [Indexed: 07/08/2023]
Abstract
Cushing's adenoma invading the cavernous sinus requires aggressive resection to be cured. MRI is frequently inconclusive for identifying microadenomas, and visualizing the involvement of the medial cavernous sinus is even more challenging. In this video, the authors present a patient with an adrenocorticotropic hormone (ACTH)-producing microadenoma with doubtful left medial cavernous sinus involvement on MRI. She underwent an endoscopic endonasal exploration of the medial compartment of the cavernous sinus. The abnormally thickened wall, confirmed by intraoperative endoscopic endonasal ultrasound, was safely excised using the "interdural peeling" technique. Complete resection of the tumor resulted in normalization of her postoperative cortisol levels and disease remission with no complications. The video can be found here: https://stream.cadmore.media/r10.3171/2023.4.FOCVID22150.
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Affiliation(s)
| | | | | | - Basit Jawad
- Otolaryngology, The Ohio State University Wexner Medical Center, Columbus; and
| | - Joshua Vignolles-Jeong
- The Ohio State University College of Medicine, The Ohio State University, Columbus, Ohio
| | - Ricardo L. Carrau
- Otolaryngology, The Ohio State University Wexner Medical Center, Columbus; and
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Yanez-Siller JC, Noiphithak R, Porto E, Beer-Furlan AL, Revuelta Barbero JM, Martinez-Perez R, Howe E, Prevedello DM, Carrau RL. Endoscopic Approaches to the Paramedian Skull Base: An Anatomic Comparison of Contralateral Endonasal and Transmaxillary Strategies. Oper Neurosurg (Hagerstown) 2023; 24:e421-e428. [PMID: 36746000 DOI: 10.1227/ons.0000000000000637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/29/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The expanded endoscopic endonasal approach (EEA) is limited laterally by the internal carotid artery (ICA). The EEA to the paramedian skull base often requires complex maneuvers such as dissection of the Eustachian tube (ET) and foramen lacerum (FL), and ICA manipulation. An endoscopic contralateral transmaxillary approach (CTMA) has the potential to provide adequate exposure of the paramedian skull base while bypassing manipulation of the aforementioned anatomic structures. OBJECTIVE To quantify and compare the surgical nuances of a CTMA and a contralateral EEA when approaching the paramedian skull base in cadaveric specimens. METHODS Five adult cadaveric heads were dissected bilaterally (10 sides) using a contralateral EEA and a CTMA to expose targets of interest at the paramedian skull base. For each target in both approaches, the surgical freedom, angle of attack, the corridor's "perspective angle," and "turning angle" to circumvent the ICA, ET, and FL were obtained. RESULTS The CTMA achieved superior surgical freedom at all targets ( P < .05) except at the root entry point of cranial nerve XII. The CTMA provided superior vertical and horizontal angles of " attack " to the majority of targets of interest. Except when approaching the root entry point of cranial nerve XII, the CTMA " turning angle " around the ICA, ET, and FL were wider with CTMA for all targets. CONCLUSION A CTMA complements the EEA to access the paramedian skull base. A CTMA may limit the need for complex maneuvers such as ICA mobilization and dissection of the ET and FL when approaching the paramedian skull base.
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Affiliation(s)
- Juan C Yanez-Siller
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri-Columbia, Columbia, Missouri, USA
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Raywat Noiphithak
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Edoardo Porto
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Andre L Beer-Furlan
- Department of Neurosurgery, Houston Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Juan M Revuelta Barbero
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Rafael Martinez-Perez
- Department of Neurosurgery, Geisinger Commonwealth School of Medicine, Wilkes Barre, Pennsylvania, USA
| | - Edmund Howe
- University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA
| | - Daniel M Prevedello
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
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Alsavaf MB, Wu KC, Finger G, Salem EH, Castello Ruiz MJ, Godil SS, Ghalib L, Carrau RL, Prevedello DM. A silent corticotroph adenoma: making the case for a pars intermedia origin. Illustrative case. J Neurosurg Case Lessons 2023; 5:CASE2350. [PMID: 37212418 PMCID: PMC10550526 DOI: 10.3171/case2350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 03/08/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Silent corticotroph adenomas (SCAs) are the only pituitary adenomas thought to originate from the pars intermedia. This case report presents the rare finding of a multimicrocystic corticotroph macroadenoma displacing the anterior and posterior lobes of the pituitary gland on magnetic resonance imaging (MRI). This finding supports the hypothesis that silent corticotroph adenomas may originate from the pars intermedia and should be considered in the differential for tumors arising from this location. OBSERVATIONS A 55-year-old man presented with an episode of confusion and blurred vision. MRI demonstrated separation of the anterior and posterior glands by a solid-cystic lesion located within the pars intermedia that superiorly displaced the optic chiasm. Endocrinologic evaluation was unremarkable. The differential diagnosis included pituitary adenoma, Rathke cleft cyst, and craniopharyngioma. The tumor was confirmed to be an SCA on pathology and was completely removed through the endoscopic endonasal transsphenoidal approach. LESSONS The case highlights the importance of preoperative screening for subclinical hypercortisolism for tumors arising from this location. Knowledge of a patient's preoperative functional status is critical and dictates their postoperative biochemical assessment to determine remission. The case also illustrates surgical strategies for resecting pars intermedia lesions without injuring the gland.
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Affiliation(s)
| | - Kyle C. Wu
- Neurological Surgery, and
- The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, Ohio
| | | | - Eman H. Salem
- Department of Otolaryngology, Faculty of Medicine, Mansoura University, Mansoura, Egypt; and
| | | | - Saniya S. Godil
- Neurological Surgery, and
- The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, Ohio
| | - Luma Ghalib
- Endocrinology, Diabetes, and Metabolism, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Ricardo L. Carrau
- Departments of Otolaryngology–Head and Neck Surgery
- Neurological Surgery, and
- The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, Ohio
| | - Daniel M. Prevedello
- Departments of Otolaryngology–Head and Neck Surgery
- Neurological Surgery, and
- The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, Ohio
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Gosal JS, Bhuskute GS, Alsavaf MB, Wu KC, Salem EH, Jawad B, Kelly KM, Carrau RL, Prevedello DM. Endoscopic Endonasal Transcavernous Posterior Clinoidectomy With Inferior Hypophyseal Artery Preservation for a Cavernous Sinus Hemangioma: Technical Case Report. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00671. [PMID: 37039583 DOI: 10.1227/ons.0000000000000675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 01/11/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Unilateral inferior hypophyseal artery (IHA) sacrifice is routinely performed during endoscopic endonasal transcavernous interdural posterior clinoidectomy. However, unilateral IHA sacrifice presents the risk of temporary postoperative diabetes insipidus. We present a case demonstrating the feasibility of endoscopic endonasal transcavernous posterior clinoidectomy without IHA sacrifice. CLINICAL PRESENTATION A 62-year-old man presented with progressive weakness of his left oculomotor and abducens nerves. MRI of the brain revealed a small lesion suspicious for hemangioma in the posterior compartment of the left cavernous sinus. Following an endoscopic endonasal transcavernous approach using the interdural peeling technique, an IHA-sparing posterior clinoidectomy was performed to provide access to the tumor in the posterior cavernous sinus. After complete resection, the patient's symptoms improved and a diagnosis of cavernous sinus hemangioma was confirmed by histopathology. CONCLUSION Unilateral IHA preservation may be performed safely when performing a transcavernous interdural posterior clinoidectomy. IHA preservation can be readily achieved if the artery is redundant, the lesion is small and located in the posterior cavernous sinus, and there is a short posterior clinoid, ultimately avoiding the risk of transient postoperative diabetes insipidus.
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Affiliation(s)
- Jaskaran S Gosal
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
- Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Govind S Bhuskute
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Mohammad Bilal Alsavaf
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Kyle C Wu
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Eman H Salem
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Basit Jawad
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Kathleen M Kelly
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Otolaryngology-Head & Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of the Ohio State University College of Medicine, Columbus, Ohio, USA
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Zachariah MA, Cua S, Muhlestein WE, Otto BA, Carrau RL, Kirschner LS, Ghalib LM, Lonser RR, Hardesty DA, Prevedello DM. Intraoperative Predictor of Remission in Cushing Disease. Oper Neurosurg (Hagerstown) 2023; 24:460-467. [PMID: 36701661 DOI: 10.1227/ons.0000000000000560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 09/30/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Cushing disease represents a challenge for neurosurgeons, with high recurrence rates reported. Characteristics associated with remission are incompletely understood; thus, an intraoperative predictor for outcome would be valuable for assessing resection of adrenocorticotropic hormone (ACTH) secreting tissue. OBJECTIVE To evaluate whether intraoperative ACTH measurement could predict outcome after surgery for Cushing disease. METHODS Retrospective cohort study of 55 consecutive encounters with Cushing disease who had peripheral plasma ACTH levels measured intraoperatively before, during, and after tumor resection. The primary outcome measure was remission, defined by either 2 negative 24-hour urine free cortisol or 2 negative midnight salivary cortisol measurements. A logistic regression machine learning model was generated using recursive feature elimination. RESULTS Fifty-five operative encounters, comprising 49 unique patients, had a mean follow-up of 2.73 years (±2.11 years) and a median follow-up of 2.07 years. Remission was achieved in 69.1% (n = 38) of all operations and in 78.0% (n = 32) of those without cavernous sinus invasion. The final ACTH level measured intraoperatively correctly predicted outcome (area under the curve = 0.766; P value = .002). The odds ratio of remission in patients with the lowest quartile vs highest quartile final intraoperative ACTH was 23.4 ( P value = .002). Logistic regression machine learning model resulted in incorporating postoperative day 1 morning cortisol, final intraoperative ACTH that predicted outcome with an average area under the curve of 0.80 ( P = .0027). CONCLUSION Intraoperative ACTH may predict outcome after surgery in Cushing disease; furthermore, investigation is warranted.
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Affiliation(s)
- Marcus A Zachariah
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA.,Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Santino Cua
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Whitney E Muhlestein
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Bradley A Otto
- Department of Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Lawrence S Kirschner
- Department of Endocrinology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Luma M Ghalib
- Department of Endocrinology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Russell R Lonser
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Douglas A Hardesty
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
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Castello Ruiz MJ, Alsavaf MB, Fadel M, Salem EH, Mongkolkul K, Naksen P, Godil SS, Otto BA, Carrau RL, Prevedello DM. Spontaneous rhinorrhea: a possible concealing initial symptom of ecchordosis physaliphora. Illustrative case. J Neurosurg Case Lessons 2023; 5:CASE236. [PMID: 37014027 PMCID: PMC10550575 DOI: 10.3171/case236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/23/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Spontaneous rhinorrhea may be the initial manifestation of ecchordosis physaliphora (EP). There are currently 47 published cases of symptomatic EP, with spontaneous rhinorrhea being one of the most prevalent symptoms. The authors report 1 case as a cause of cerebrospinal fluid (CSF) fistula. OBSERVATIONS A 46-year-old woman presented to the authors' clinic with meningitis secondary to nasal CSF leakage. The computed tomography (CT) scan indicated an imperceptibly thin/dehiscent focus along the posterior wall of the sphenoid air cell's midline. A tumor was identified during endoscopic endonasal CSF repair surgery. EP was diagnosed in the frozen and final pathology. LESSONS EP should be considered as a potential cause of spontaneous rhinorrhea. This initial clinical manifestation accounts for 35% of symptomatic EP cases. The prepontine and posterior sphenoid sinus wall appear to be the locations with the highest susceptibility. Surgical therapy of the fistula without excision of the lesion may result in insufficient issue resolution and recurrence.
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Affiliation(s)
| | - Mohammad Bilal Alsavaf
- Department of Otolaryngology–Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Michael Fadel
- Department of Otolaryngology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Eman H. Salem
- Department of Otolaryngology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Kittichai Mongkolkul
- Department of Otolaryngology–Head and Neck Surgery, Rajavithi Hospital, The College of Medicine of Rangsit University, Bangkok, Thailand
| | - Pakjira Naksen
- Department of Otolaryngology, Phramongkutklao Hospital, Bangkok, Thailand; and
| | - Saniya S. Godil
- Department of Neurological Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Bradley A. Otto
- Department of Otolaryngology–Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Ricardo L. Carrau
- Department of Otolaryngology–Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Daniel M. Prevedello
- Department of Neurological Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
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Alsavaf MB, Prevedello DM. Letter: Chordoma and Ecchordosis Physaliphora: Two Sides of the Same Coin. Neurosurgery 2023; 92:e116-e117. [PMID: 36877027 DOI: 10.1227/neu.0000000000002451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 03/07/2023] Open
Affiliation(s)
- Mohammad Bilal Alsavaf
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA.,Department of Neurological Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA.,Department of Neurological Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
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Revuelta Barbero JM, Porto E, Prevedello DM, Noiphithak R, Yanez-Siller JC, Martinez-Perez R, Pradilla G. Quantitative Comparative Analysis of the Endoscope-Assisted Expanded Retrosigmoid Approach and the Far-Lateral Approach to the Inframeatal Area: An Anatomic Study With Surgical Implications. Oper Neurosurg (Hagerstown) 2023; 24:e187-e200. [PMID: 36701685 DOI: 10.1227/ons.0000000000000506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/07/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The inframeatal area (IFMA) is a complex anatomic region of the posterior cranial fossa. Given its deep-seated location, tumors involving the IFMA represent a surgical challenge. OBJECTIVE To objectively compare the endoscope-assisted expanded retrosigmoid approach (ERSA) and the far-lateral supracondylar transtubercular approach (FLTA) to address the IFMA. METHODS Anatomic dissections were performed on 5 cadaveric heads (10 sides). The ERSAs were performed before and after the FLTAs. The surgical exposure, surgical freedom, and angles of attack to the IFMA were measured and compared for each approach. In addition, 2 illustrative clinical cases are reported. RESULTS Compared with FLTA, ERSA yielded a nonsignificantly smaller mean area of exposure, whereas FLTA provided a significantly larger mean area of surgical freedom, compared with ERSA ( P = .002). The mean horizontal and vertical angles of attack were significantly different between the approaches. In the vertical plane, FLTA yielded the broadest angle of attack at the root entry zone of the lower cranial nerves (CN; P < .004), whereas ERSA did so at the dural entry zone of CN VII/VIII ( P = .006). In the horizontal plane, FLTA achieved its broadest angle of attack at the root entry zone of the lower CNs ( P = 1.83) while ERSA at the dural entry zone of CN VII/VIII ( P = .37). CONCLUSION ERSA and FLTA granted a comparable exposure with the IFMA. Although FLTA may afford a larger area of surgical freedom, ERSA may be a suitable alternative to approach the IFMA, particularly to reach the most medial and superior aspects of this region. Conversely, FLTA may facilitate access to more caudally targets.
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Affiliation(s)
- J Manuel Revuelta Barbero
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
- Department of Neurosurgery, Medical College of Georgia, Augusta, Georgia, USA
| | - Edoardo Porto
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Raywat Noiphithak
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Juan C Yanez-Siller
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Rafael Martinez-Perez
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
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Hoang AN, McGahan BG, Cua S, Magill ST, Nayak P, Montaser AS, Ghalib L, Prevedello LM, Hardesty DA, Carrau RL, Prevedello DM. Pituitary Stalk Stretch Predicts Postoperative Diabetes Insipidus After Pituitary Macroadenoma Transsphenoidal Resection. Oper Neurosurg (Hagerstown) 2023; 24:248-255. [PMID: 36701694 DOI: 10.1227/ons.0000000000000501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 09/07/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Manipulation of the pituitary stalk, posterior pituitary gland, and hypothalamus during transsphenoidal pituitary adenoma resection can cause disruption of water electrolyte regulation leading to diabetes insipidus (DI). OBJECTIVE To determine whether pituitary stalk stretch is an independent risk factor for postoperative DI after pituitary adenoma resection. METHODS A retrospective review was performed of patients undergoing endoscopic endonasal resection of pituitary macroadenoma between July 2010 and December 2016 by a single neurosurgeon. We analyzed preoperative and postoperative imaging metrics to assess predictors for postoperative DI. RESULTS Of the 234 patients undergoing resection, 41 (17.5%) developed postoperative DI. DI was permanent in 10 (4.3%) and transient in 31 (13.2%). The pituitary stalk stretch, measured as the change in stalk length from preoperative to postoperative imaging, was greater in the DI compared with the non-DI group (10.1 mm vs 5.9 mm, P < .0001). The pituitary stalk stretch was associated with DI with significant difference in mean pituitary stalk stretch between non-DI group vs DI group (5.9 mm vs 10.1 mm, P < .0001). Multivariate analysis revealed that pituitary stalk stretch >10 mm was a significant independent predictor of postoperative DI [odds ratios = 2.56 (1.10-5.96), P = .029]. When stratified into transient and permanent DI, multivariable analysis showed that pituitary stalk stretch >10 mm was a significant independent predictor of transient DI [odds ratios = 2.71 (1.0-7.1), P = .046] but not permanent DI. CONCLUSION Postoperative pituitary stalk stretch after transsphenoidal pituitary adenoma surgery is an important factor for postoperative DI. We propose a reconstruction strategy to mitigate stalk stretch.
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Affiliation(s)
- Alex Nguyen Hoang
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Benjamin G McGahan
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Santino Cua
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Stephen T Magill
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois, USA
| | - Pratima Nayak
- Department of Endocrinology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alaa S Montaser
- Department of Neurological Surgery, Ain Shams University, Cairo, Egypt
| | - Luma Ghalib
- Department of Endocrinology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Luciano M Prevedello
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Douglas A Hardesty
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Yanez-Siller JC, Noiphithak R, Martinez-Perez R, Dallan I, Moe KS, Revuelta Barbero JM, Howe E, Prevedello DM, Carrau RL. The "Crista Ovale": A Reliable Anatomical Landmark in Transorbital Endoscopic Approaches to the Middle Cranial Fossa. Oper Neurosurg (Hagerstown) 2023; 24:e172-e177. [PMID: 36701753 DOI: 10.1227/ons.0000000000000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/04/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Transorbital endoscopic approaches (TOEAs) have emerged as adjunct and alternatives for accessing the middle cranial fossa (MCF). Nuances of the skull base anatomy from a ventral transorbital endoscopic viewpoint remain to be fully described. OBJECTIVE To assess the anatomy of the "crista ovale" (COv), described transcranially as the midsubtemporal ridge (MSR), from a ventral transorbital perspective and evaluate its role as a landmark in TOEA to the MCF. METHODS Lateral TOEAs to the MCF were performed in 20 adult cadaveric heads (40 sides). The presence of the COv/MSR was evaluated under endoscopic visualization. Anatomic relationships between COv/MSR and surrounding structures were assessed. The presence of COv/MSR was also examined in 30 cadaveric head computed tomography (CT) scans (60 sides). RESULTS The COv/MSR was identified in 98% (39/40) of sides at the MCF, as 1 of 4 major configurations. The COv/MSR was found anterolateral to the foramen ovale and foramen spinosum (mean distance: 9.2 ± SD 2.4 mm and 12.3 ± SD 2.6 mm, respectively) directly anterior or anteromedial to the petrous apex (mean distance: 26.2 ± SD 2.6 mm) and at a mean 47.6 ± SD 4.7 mm from the approach's surgical portal. It was recognized in 95% (57/60) of CT scans. CONCLUSION The COv/MSR can be readily identified during TOEA to the MCF and on CT. It serves as a reliable landmark to localize the foramen ovale, foramen spinosum, and petrous apex. Further studies may confirm its surgical significance in transorbital endoscopic procedures.
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Affiliation(s)
- Juan C Yanez-Siller
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri-Columbia, Columbia, Missouri, USA
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Raywat Noiphithak
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Rafael Martinez-Perez
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
- Department of Neurosurgery, Geisinger Commonwealth School of Medicine, Wilkes Barre, Pennsylvania, USA
| | - Iacopo Dallan
- Department of Otolaryngology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Kris S Moe
- Larrabee Center for Facial Plastic Surgery, Seattle, Washington, USA
| | - Juan M Revuelta Barbero
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Edmund Howe
- University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA
| | - Daniel M Prevedello
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri-Columbia, Columbia, Missouri, USA
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri-Columbia, Columbia, Missouri, USA
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
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46
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Robbins AC, Winter KA, Smalley ZP, Godil S, Luzardo G, Washington CW, Prevedello DM, Stringer SP, Zachariah M. Side-Firing Intraoperative Ultrasonograhy for Resection of Giant Pituitary Adenomas. World Neurosurg 2023; 173:79-87. [PMID: 36796627 DOI: 10.1016/j.wneu.2023.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Suprasellar extension, cavernous sinus invasion, and involvement of intracranial vascular structures and cranial nerves are among the challenges faced by surgeons operating on giant pituitary macroadenomas. Intraoperative tissue shifts may render neuronavigation techniques inaccurate. Intraoperative magnetic resonance imaging can solve this problem, but it may be costly and time consuming. However, intraoperative ultrasonography (IOUS) allows for quick, real-time feedback and may be particularly useful when facing giant invasive adenomas. Here, we present the first study examining technique for IOUS-guided resection specifically focusing on giant pituitary adenomas. OBJECTIVE To describe the use of a side-firing ultrasound probe in the resection of giant pituitary macroadenomas. METHODS We describe an operative technique using a side-firing ultrasound probe (Fujifilm/Hitachi) to identify the diaphragma sellae, confirm optic chiasm decompression, identify vascular structures related to tumor invasion, and maximize extent of resection in giant pituitary macroadenomas. RESULTS Side-firing IOUS allows for identification of the diaphragma sellae to help prevent intraoperative cerebrospinal fluid leak and maximize extent of resection. Side-firing IOUS also aids in confirmation of decompression of the optic chiasm via identification of a patent chiasmatic cistern. Furthermore, direct identification of the cavernous and supraclinoid internal carotid arteries and arterial branches is achieved when resecting tumors with significant parasellar and suprasellar extension. CONCLUSIONS We describe an operative technique in which side-firing IOUS may assist in maximizing extent of resection and protecting vital structures during surgery for giant pituitary adenomas. Use of this technology may be particularly valuable in settings in which intraoperative magnetic resonance imaging is not available.
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Affiliation(s)
- Austin C Robbins
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - K Austin Winter
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Zachary P Smalley
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Saniya Godil
- Department of Neurosurgery, Wexner Medical Center, Ohio State University, Columbus, Ohio, USA
| | - Gustavo Luzardo
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Chad W Washington
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, Ohio State University, Columbus, Ohio, USA
| | - Scott P Stringer
- Department of Otolaryngology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Marcus Zachariah
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA.
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Mongkolkul K, Alsavaf MB, Salem EH, VanKoevering KK, Kelly K, Hardesty DA, Prevedello DM, Carrau RL. Endoscopic Multiport Approach for Exenteration of the Infratemporal Fossa. Laryngoscope 2023; 133:1367-1374. [PMID: 36752574 DOI: 10.1002/lary.30611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/18/2023] [Accepted: 01/22/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE To demonstrate anatomic relationships pertinent to the endoscopic multiport approach to the infratemporal fossa (ITF). Discuss advantages and limitations of each individual approach. STUDY DESIGN Cadaveric study. METHODS Endoscopic and endoscopic-assisted endonasal transpterygoid, sublabial transmaxillary, endoscopic transorbital, and endoscopic transoral approaches to accessing the ITF were completed in five silicone-injected fresh cadaveric specimens (10 sides) with the assistance of 0, 30, and 450 rods-lens endoscopes. Image guidance was used to confirm and document the anatomical relationships encountered in each approach. RESULTS The endonasal endoscopic transpterygoid approach provides better visualization and more direct exposure to median structures. Endoscopic-assisted sublabial transmaxillary approach enhances the field of exposure, angle of attack, and ease of instrumentation to the lateral part of the ITF. Endoscopic-assisted transorbital approach via the inferior orbital fissure provided cephalic and anterior access. Endoscopic-assisted transoral approach complements the access to lesions extending inferior to the hard palate or far lateral to the mandibular condyle. CONCLUSIONS A combination of minimal access infratemporal approaches can provide adequate exposure of the entire ITF while avoiding some of the morbidity associated with open approaches. LEVEL OF EVIDENCE NA Laryngoscope, 2023.
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Affiliation(s)
- Kittichai Mongkolkul
- Department of Otolaryngology-Head & Neck Surgery, Faculty of Excellence Center in Otolaryngology-Head & Neck Surgery Rajavithi Hospital, Bangkok, Thailand.,Department of Otolaryngology-Head & Neck Surgery, Rangsit University College of Medicine, Bangkok, Thailand
| | - Mohammad Bilal Alsavaf
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Eman H Salem
- Department of Otolaryngology-Head & Neck Surgery, Mansoura University Hospitals, Mansoura, Egypt
| | - Kyle K VanKoevering
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Kathleen Kelly
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Douglas A Hardesty
- Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA.,Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA.,Department of Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, USA
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48
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Finger G, Wu KC, Godil SS, Carrau RL, Hardesty D, Prevedello DM. Ultrasound-guided endoscopic endonasal resection of sellar and suprasellar craniopharyngiomas. Front Surg 2023; 10:1073736. [PMID: 36896257 PMCID: PMC9990524 DOI: 10.3389/fsurg.2023.1073736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/31/2023] [Indexed: 02/19/2023] Open
Abstract
Introduction Optimal planning and minimally invasive surgical approach are essential to complete craniopharyngiomas (CP) resection with limited postoperative morbidity. Given the nature of craniopharyngioma recurrence, complete resection of the neoplasm is crucial. Since CP arise from the pituitary stalk and may grow anteriorly or laterally, some cases require an extended endonasal craniotomy. The extension of the craniotomy is crucial to expose the whole tumor and to make its dissection from the surrounding structures feasible. In order to guide the extension of the approach, the intraoperative use of ultrasound is helpful for the surgeons. The objective of this paper is to describe and to demonstrate the applicability of the utilization of intraoperative ultrasound (US) guidance for planning and confirmation of craniopharyngioma resection in EES. Method The authors selected one operative video of a sellar-suprassellar craniopharyngioma gross-totally resected by EES. The authors demonstrate the extended sellar craniotomy, the anatomic landmarks that guide bone drilling and dural opening, the aspect of the intraoperative real time US, tumor resection and dissection from the surrounding structures. Results The solid component of the tumor was mostly isoechogenic in texture compared to the anterior pituitary gland, with several wide spread hyperechogenic images corresponding to calcifications and hypoechogenic vesicles corresponding to cysts inside the CF ("salt-and-pepper" pattern). Discussion The intraoperative endonasal US is a new surgical tool that allows for real-time active imaging for skull base procedures, such as sellar region tumors. Besides tumor evaluation, the intraoperative US helps the neurosurgeon to determine the size of craniotomy, to anticipate the relation between the tumor and vascular structures and to guide the best strategy for gross-total resection of the tumor. Conclusion The EES allows a straight access to the craniopharyngiomas located in the sellar region or that grow anteriorly or superiorly. This approach allows the surgeon to dissect the tumor with minimal manipulation of the surrounding structures, when compared to craniotomy approaches. In order to accomplish that, the use of intraoperative endonasal ultrasound helps the neurosurgeon to perform the most suitable strategy, optimizing the rate of success.
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Affiliation(s)
- Guilherme Finger
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Kyle C Wu
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Sanyia S Godil
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Ricardo L Carrau
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, OH, United States
| | - Douglas Hardesty
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University College of Medicine, Columbus, OH, United States
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49
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Zachariah MA, Bozer JJ, Cua S, Prevedello LM, Ghalib LM, Hardesty DA, Carrau RL, Kirschner LS, Prevedello DM. Intraoperative Prediction of Long-Term Remission in Acromegaly. Oper Neurosurg (Hagerstown) 2023; 24:74-79. [PMID: 36317950 DOI: 10.1227/ons.0000000000000421] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 07/14/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The features of long-term remission in acromegaly adenomectomy are incompletely understood. An intraoperative predictor for long-term outcome would be valuable for assessing resection of growth hormone (GH)-secreting tumors in real-time. OBJECTIVE To evaluate whether intraoperative GH measurement could predict long-term outcomes for acromegaly. METHODS In 47 patients, peripheral blood GH levels were measured thrice intraoperatively: once before tumor dissection, once during tumor dissection, and once after tumor dissection. Long-term remission was defined by age-appropriate, normalized insulin-like growth factor-1 at most recent follow-up and a random GH less than 1.0 ng/mL. Patients were only considered to be in long-term remission without the use of postoperative medical therapy for acromegaly or radiation therapy. RESULTS The median length of follow-up was 4.51 (range: 0.78-9.80) years. Long-term remission was achieved in 61.7% (29/47) of operations. Like previous studies, cavernous sinus invasion (odds ratio [OR]: 0.060; 95% CI: 0.014-0.260; P value < .01), suprasellar extension (OR: 0.191; 95% CI: 0.053-0.681; P value<.01), and tumor size greater than 1 cm (OR: 0.177; 95% CI: 0.003-0.917; P value = .03) were associated with not being in long-term remission. The minimum GH measured intraoperatively predicted long-term outcome (area under the curve: 0.7107; 95% CI: 0.537-0.884; P value < .01). The odds ratio of remission in patients with the lowest quartile minimum intraoperative GH compared with patients with the highest quartile minimum intraoperative GH was 27.0 (95% CI: 2.343-311.171; P value < .01). CONCLUSION Minimum intraoperative GH may predict long-term outcome for acromegaly, which in principle could provide the pituitary neurosurgeon with real-time feedback and inform intraoperative decision making.
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Affiliation(s)
- Marcus A Zachariah
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Jordan J Bozer
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Santino Cua
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Luciano M Prevedello
- Department of Neuroradiology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Luma M Ghalib
- Department of Endocrinology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Douglas A Hardesty
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Lawrence S Kirschner
- Department of Endocrinology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
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50
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Li L, London NR, Prevedello DM, Carrau RL. Endonasal Exposure of Lateral Recess of the Sphenoid Sinus: Significance of Pterygoid Process Pneumatization. Am J Rhinol Allergy 2022; 37:291-297. [PMID: 36373591 DOI: 10.1177/19458924221139019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Caudal pneumatization of the pterygoid process may impact endonasal exposure of the lateral recess of sphenoid sinus (LRSS). Objectives This study aims to explore the implications of a pneumatized pterygoid process for an endonasal transpterygoid approach to the LRSS and to define strategies regarding the preservation or sacrifice of the vidian nerve. Methods Dissection of the LRSS (11 sides) was performed on 6 cadaveric specimens, preselected for the radiographic presence of an LRSS. In addition, the dimensions of the LRSS were measured on the deidentified CT images of 120 patients (240 sides). The sphenoid sinus was subdivided into 3 categories: Type 1 (no identifiable LRSS), Type 2 (lateral pneumatization of the greater wing above the vidian canal), and Type 3 (pneumatization of both the greater wing and the pterygoid process). Results On the cadaveric specimens, a Type 2 pneumatization often allowed access to the LRSS above the level of the vidian canal; thus, sparing the vidian neurovascular bundle. In Type 3 pneumatization, a frontal corridor through the pterygoid base could be created to reach the LRSS with preservation of the vidian nerve. Extreme Type 3 pneumatization, however, required the transposition or sacrifice of the vidian nerve to facilitate a full direct access to the superolateral LRSS. Measurements on CT images revealed that the extent of caudal pneumatization of the pterygoid process had no statistically significant correlation with the superolateral extension of the lateral recess in patients with Type 3 LRSS ( P > .05). Conclusion Pneumatization of the LRSS toward a caudal or superolateral direction may develop independent from each other. Caudal pneumatization of the pterygoid process seems to variably impact the endonasal exposure of the LRSS.
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Affiliation(s)
- Lifeng Li
- Department of Otolaryngology–Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Department of Otolaryngology–Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio
| | - Nyall R London
- Department of Otolaryngology–Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Daniel M Prevedello
- Department of Otolaryngology–Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio
- Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio
| | - Ricardo L Carrau
- Department of Otolaryngology–Head and Neck Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio
- Department of Neurological Surgery, The James Cancer Hospital at the Wexner Medical Center of The Ohio State University, Columbus, Ohio
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