Endoscopic Endonasal Surgery for Tumors of the Cavernous Sinus: A Series of 234 Patients.

BACKGROUND: Cavernous sinus (CS) tumors often are considered inoperable. We present our experience with endoscopic endonasal surgery (EES) and compare the outcomes for different tumor. METHODS: EES (medial or lateral approach) was used in 234 patients with CS tumors. The cohort included 175 (75%) pituitary adenomas and 59 (25%) nonadenomatous lesions. RESULTS: Presenting symptoms were significantly different between the 2 groups, with cranial neuropathies occurring mainly in nonadenomas (P < 0.0001). The overall gross total tumor resection rate from the CS was 37.3% (37.1% in adenomas, 38.1% in non-adenomas). In total, preexisting cranial nerve (CN) dysfunction improved in 56.4% of the patients. After treatment completion (including radiation of residual tumor), 83.3% of acromegalic patients, 50% of prolactinomas and 33.3% of Cushing's disease, were in remission. Visual loss improved in 86.8% of adenomas and in 70.8% of nonadenomas. Intracavernous CN palsies improved in 77.3% of adenomas and 42.4% of nonadenomas. New permanent CN palsies occurred in 7 nonadenomas, which is significantly greater than in adenomas (P = 0.007). The leak rate of cerebrospinal fluid was 6.3% for adenomas and 11.9% for nonadenomas. Four patients suffered an internal carotid artery injury with no neurologic sequelae in 3 cases and 1 death (0.4%). CONCLUSIONS: EES provides an easily accessible midline corridor to the CS with equivalent or superior results to transcranial approaches in the management of select tumors. Symptomatology due to CS invasion is more likely to improve in pituitary adenomas and the rate of surgical complications is greater in nonadenomas. Using a team approach, the overall mortality due to vascular injury is low.

Outcomes of Endonasal and Lateral Approaches to Petroclival Meningiomas.

OBJECTIVE: Transpetrosal approaches for the treatment of petroclival meningiomas are often associated with substantial morbidity and long recovery. With the goal of early clinical improvement, we have used less invasive surgical approaches for petroclival meningiomas. METHODS: We retrospectively reviewed 32 patients with petroclival meningiomas. Eleven patients (34.4%) were managed with lateral approaches (retrosigmoid or far lateral approach), 17 (53.1%) with anterior midline approaches (endoscopic endonasal approach [EEA]), and 4 (12.5%) with a combination. RESULTS: The average Karnofsky Performance Score (KPS) at presentation was 73.8. The average postoperative KPS improved to 87.9 (P < 0.001) during short-term follow-up of 14 months (range, 1-42) and was significantly higher in primary tumors (P = 0.013), tumors <4 cm (P = 0.039), and tumors without vascular encasement (P = 0.002) but remained significant regardless of age, tumor size, or vascular encasement. The greatest benefit occurred with primary tumors, in young patients and in those who underwent nontotal resection (P < 0.001). EEA had a significantly greater potential for improved KPS (P = 0.002). Gross (n = 6) or near total (n = 9) resection was achieved in 15 of 32 cases (47%). Complications included new cranial nerve palsies affecting mainly the abducens nerve (18.7%). New lower cranial nerve palsies occurred in only 1 case (3.1%). Other complications included postoperative hydrocephalus (15.6%) and cerebrospinal fluid leak (28.1%). One patient died in the perioperative period (3.1%). CONCLUSIONS: In the short-term, less aggressive cranial base approaches, including retrosigmoid exposures and the recently introduced EEA, are effective alternatives to transpetrosal approaches for debulking petroclival meningiomas with significant early clinical improvement and limited major surgical complications.

Intrasphenoid septations inserted into the internal carotid arteries: a frequent and risky relationship in transsphenoidal surgeries.

INTRODUCTION: When an expanded endonasal transsphenoidal surgical approach is performed, intrasphenoid septations must be completely resected. If these structures are close to the internal carotid artery (ICA), then their manipulation might cause vascular injury. OBJECTIVE: The objective of this study is to describe the frequency of intrasphenoid septations in the internal carotid artery protuberance (ICAp). METHODS: Computed tomography (CT) scans of 421 patients were analysed. Intrasphenoid septations (classified as intersphenoid or accessory) and their relationship to the ICAp were described. Additionally, a sphenoid sinus classification was performed based on their degree of pneumatisation to determine whether a difference exists in the frequency of intrasphenoid septations inserted into ICAp with regard to sinus type. RESULTS: The patient mean age was 39±21.4 years. Overall, 219 patients (52%) had septations in the ICAp; 359 patients (85.3%) had intersphenoid septations; of the latter, 135 (37.6%) had septations in the ICAp. This frequency was higher among patients with sphenoid sinus type 4 or 5 (44.7% and 43.5%, respectively). Accessory septations were found in 255 patients (60.6%); 140 of these septations (54.9%) were in the ICAp. Among 351 patients with types 3, 4 or 5 sphenoid sinuses (i.e., only well-pneumatised sphenoid sinuses), 219 (62.4%) had septations in the ICAp. These frequencies are higher than those reported in most previous studies. CONCLUSION: The frequency of intrasphenoid septations in the ICAp found is considerable. It is higher among patients with more pneumatised sinuses. This finding justifies an appropriate pre-operative study, and careful attention must be paid during transsphenoidal surgery.

Comparison of endoscopic endonasal and bifrontal craniotomy approaches for olfactory groove meningiomas: A matched pair analysis of outcomes and frontal lobe changes on MRI.

We compare the outcomes and postoperative MRI changes of endoscopic endonasal (EEA) and bifrontal craniotomy (BFC) approaches for olfactory groove meningiomas (OGM). All patients who underwent either BFC or EEA for OGM were eligible. Matched pairs were created by matching tumor volumes of an EEA patient with a BFC patient, and matching the timing of the postoperative scans. The tumor dimensions, peritumoral edema, resectability issues, and frontal lobe changes were recorded based on preoperative and postoperative MRI. Postoperative fluid-attenuated inversion recovery (FLAIR) hyperintensity and residual cystic cavity (porencephalic cave) volume were compared using univariable and multivariable analyses. From a total of 70 patients (46 EEA, 24 BFC), 10 matched pairs (20 patients) were created. Three patients (30%) in the EEA group and two (20%) in the BFC had postoperative cerebrospinal fluid leaks (p=0.61). Gross total resections were achieved in seven (70%) of the EEA group and nine (90%) of the BFC group (p=0.26), and one patient from each group developed a recurrence. On postoperative MRI, there was no significant difference in FLAIR signal volumes between EEA and BFC approaches (6.9 versus 13.3 cm(3); p=0.17) or in porencephalic cave volumes (1.7 versus 5.0 cm(3); p=0.11) in univariable analysis. However, in a multivariable analysis, EEA was associated with less postoperative FLAIR change (p=0.02) after adjusting for the volume of preoperative edema. This study provides preliminary evidence that EEA is associated with quantifiable improvements in postoperative frontal lobe imaging.

Endonasal endoscopic surgery for squamous cell carcinoma of the sinonasal cavities and skull base: Oncologic outcomes based on treatment strategy and tumor etiology.

BACKGROUND: Oncologic outcomes for sinonasal and skull base squamous cell carcinoma (SCC) treated with an endoscopic endonasal approach (EEA) needs investigation. METHODS: Patients with SCC treated with EEA were stratified by treatment strategy and tumor etiology and reviewed. RESULTS: Thirty-four patients were treated with EEA, or which 27 had definitive resection and 7 had debulking surgery. In the definitive group, 17 had de novo tumors and 10 had tumors arising from inverted papilloma. Definitive resection was associated with better 5-year disease-free survival (DFS) and overall survival (OS) than debulking (62% vs 17%; p = .02; and 78% vs 30%; p = .03). Patients with de novo tumors had similar 5-year DFS and OS to those arising from inverted papilloma (62% vs 62%; p = .75; and 75% vs 86%; p = .24). CONCLUSION: Definitive resection of sinonasal SCC with EEA provides sound oncologic outcomes. SCC arising from inverted papilloma does not have prognostic significance.

Neuroendoscopic surgery for unilateral hydrocephalus due to inflammatory obstruction of the Monro foramen.

OBJECTIVE: Unilateral hydrocephalus (UH) is characterized by enlargement of just one lateral ventricle. In this paper, the authors will demonstrate their experiences in the neuroendoscopic management of this uncommon type of hydrocephalus. METHOD: The authors retrospectively reviewed a series of almost 800 neuroendoscopic procedures performed from September 1995 to July 2010 and selected seven adult patients with UH. Clinical and radiological charts were reviewed and analyzed. RESULTS: Six patients had intraventricular neurocysticercosis and one patient had congenital stenosis of the foramen of Monro. Headaches were the most common symptom. A septostomy restored cerebrospinal fluid circulation. During follow-up period (65.5 months, range 3-109) no patient has presented clinical recurrence as well as no severe complications have been observed. CONCLUSION: UH is a rare condition. A successful treatment can be accomplished through a neuroendoscopic approach avoiding the use of ventricular shunts.

Neuroendoscopic surgery for unilateral hydrocephalus due to inflammatory obstruction of the Monro foramen / Cirurgia neuroendoscópica para tratamento da hidrocefalia unilateral secundária à obstrução inflamatória do forame de Monro

OBJECTIVE: Unilateral hydrocephalus (UH) is characterized by enlargement of just one lateral ventricle. In this paper, the authors will demonstrate their experiences in the neuroendoscopic management of this uncommon type of hydrocephalus. METHOD: The authors retrospectively reviewed a serie of almost 800 neuroendoscopic procedures performed from September 1995 to July 2010 and selected seven adult patients with UH. Clinical and radiological charts were reviewed and analyzed. RESULTS: Six patients had intraventricular neurocysticercosis and one patient had congenital stenosis of the foramen of Monro. Headaches were the most common symptom. A septostomy restored cerebrospinal fluid circulation. During follow-up period (65.5 months, range 3-109) no patient has presented clinical recurrence as well as no severe complications have been observed. CONCLUSION: UH is a rare condition. A successful treatment can be accomplished through a neuroendoscopic approach avoiding the use of ventricular shunts.

OBJETIVO: Hidrocefalia unilateral (HU) é caracterizada pelo alargamento de apenas um dos ventrículos laterais. Neste estudo, os autores demonstraram sua experiência no manejo deste tipo incomum de hidrocefalia. MÉTODO: Foram revisados, de uma série de quase 800 cirurgias neuroendoscópicas realizadas entre Setembro de 1995 e Julho de 2010, sete pacientes adultos com diagnóstico de HU. Dados clínicos e radiológicos foram analisados. RESULTADOS: Seis pacientes tinham neurocisticercose intraventricular e um apresentava uma estenose congênita do forame de Monro. Cefaléia foi o sintoma clínico mais comum. Uma septostomia restabeleceu o fluxo liquórico. Durante o seguimento (65,5 meses, de 3-109), nenhum paciente apresentou recorrência clínica assim como nenhuma complicação grave foi observada. CONCLUSÃO: HU é uma condição rara. O tratamento satisfatório pode ser alcançado por meio de uma abordagem neuroendoscópica evitando, desta maneira, o uso de sistemas de derivação ventricular.