Combined Minimally Invasive Supraciliary and Transfacial Approach for Large Tumors with Skull Base and Sinonasal Involvement.

BACKGROUND: Tumors invading both the anterior skull base and the sinonasal area have traditionally been accessed via largely invasive open craniofacial approaches. Minimally invasive extended endoscopic endonasal approaches have recently become increasingly available but have anatomical limitations and require incremental experience and thus high patient volume. Our objective was to assess the applicability of a novel combination of the minimally invasive supraciliary incision and the limited maxillofacial osteotomy as a combined surgical approach for large tumors invading both the anterior skull base and the sinonasal area. METHODS: The well-established technique of supraciliary incision with a 2.5 × 3.0-cm craniotomy was combined for the first time with limited facial translocation approach. RESULTS: This series involves 11 cases (female/male ratio 4:7; ranging in age from 6 to 61 years). Intracranial tumor propagation with intranasal and ethmoidal extension was detected in all patients. The pathologic diagnoses included adenocarcinomas, esthesioneuroblastoma, rhabdomyosarcoma, sinonasal papilloma, meningioma, and neurofibroma. The postoperative approach-related mortality rate was zero. No case of cerebrospinal fluid leak was detected. The 3-year survival rate was 70%. CONCLUSIONS: The limited transfacial approach in combination with a supraciliary extension is associated with minimal mortality and morbidity and facilitates gross total tumor removal. We highly recommend this approach for the surgical treatment of large tumors invading both the anterior skull base and the sinonasal area, especially for those being out of indication for extended endoscopic endonasal surgery.

[Endoscopic, posterior transseptal pituitary surgery--learning curve of the surgical technique and equipment in 61 operations]. / Endoszkópos posterior transseptalis hypophysismutét. A sebészi technika fejlodése a teljes endoszkópos tumoreltávolításig 61 eset elemzése alapján.

INTRODUCTION: The removal of hypophyseal tumor by transsphenoidal pituitary surgery using microsurgical instruments was first performed over 100 years ago. Operating techniques for this surgery are constantly being renewed, first by using a microscope and later on with the use of an endoscop. The authors provide an overview of the minimal invasive posterior transseptal-transsphenoidal aproach with the combined utilization of classical techniques with the assistance of the endoscop. METHOD: Sixty-one patients (33 female, 28 male, 21-84 yrs) were treated for sellar region tumor resection using an endonasal transsphenoidal aproach with the help of an endoscope. Follow ups were performed within 2-21 months. RESULTS: Total tumor resection was successful in 91.8%, and partial resection in 8.2% of the patients. The rate of complications using the endoscopic method was not higher compared to that of the classical microscopic method. There was no major bleeding in any of the cases. Adverse events such as minor epistaxis occurred in 4.9%, transitional diabetes insipidus in 6.5%, inraoperative CSF leak in 16.67%, postoperative CSF leak in 11.5% and meningitis in 8.2% of the patients. After the operation the pathological hormonal production stoped in all patients except in two patients who were acromegalic. However their GH level normalized and they did not require further treatment, the IGF-1 still remained high. CONCLUSION: The success of the surgical treatment is based on both, the proficient pre- and postoperative endocrinological care, and the minimal invasive surgical technique. The endoscope was used partially or continuously during the operation for better visualization of the operation field in multiple angles (30 degrees, 45 degrees). It was useful in differentiating between normal and tumorous glandular tissue, and also offered an enhanced view of the intrasellar (via hydroscopy) and parasellar region. Moreover the endoscopic method is able to decrease the operating time, reduce blood loss. In different stages of the surgery, depending on the anatomical and pathological situation, switching back and forth from microscope to endoscope technique, gives us the benefit of a clearer view in each situation.

[Preliminary experience with controlled lumbar drainage in medically refractory intracranial hypertension]. / Spinalis liquorlebocsátással szerzett kezdeti tapasztalatok koponyasérülést követo befolyásolhatatlan intracranialis nyomásfokozódás kezelésében.

INTRODUCTION: The contribution of brain edema to brain swelling in cases of traumatic brain injury remains a critical problem. In head injury, the swelling and eventual rise in intracranial pressure is a frequent cause of death, and in survivors the poor prognosis with sustained elevation of ICP has been well documented. OBJECTIVE: The objective this study was to evaluate the effect of controlled lumbar cerebrospinal fluid drainage in adult patients with refractory intracranial hypertension following severe brain injury. METHOD: The study involved 10 head injured patients (GCS < or = 8) with medically refractory intracranial hypertension. Aggressive treatment included the repeated steps of the Brain Trauma Foundation's guidelines, barbiturate coma and in many cases decompressive craniectomy as well. After institution of a lumbar drain, cerebrospinal fluid drainage was maintained under control of intracranial pressure (ICP) and neurological status. ICP and cerebral perfusion pressure before and after initiation of lumbar cerebrospinal fluid drainage and related complications were documented. RESULTS: All patients demonstrated an immediate decrease of ICP (from 30.6 +/- 4.7 mm Hg to 11.5 +/- 3.9 mm Hg, mean +/- SD) and a concomitant increase of cerebral perfusion pressure. In seven patients the decrease of ICP was long lasting and 5 of them had a favourable outcome. Two patients survived with a severe permanent neurologic deficit and only three patients died because of the progressive brain edema, which developed despite of the maximum therapy. CONCLUSION: In conclusion we may consider, that controlled lumbar cerebrospinal fluid drainage is a potentially useful treatment in cases of severe traumatic brain injury when maximal medical therapy and ventricular cerebrospinal fluid evacuation have failed to control high intracranial hypertension. The danger of herniation is minimized by considering lumbar drainage in the presence of discernible basilar cisterns only.

[The role of MR angiography in predicting operative results of microvascular decompression in patients with trigeminal neuralgia]. / Az MR-angiográfia szerepe a microvascularis dekompresszióval kezelt trigeminusneuralgias betegek mutéti eredményének prognosztizálásábdan.

INTRODUCTION AND OBJECTIVES: The results of medium-term outcome of microvascular decompression (MVD) for trigeminal neuralgia are presented. The authors compare the preoperative 3-dimension magnetic resonance angiography (MRA) results with the surgical findings during MVD. Information, provided by MRA, are evaluated regarding to the prognostic significance in typical TN, atypical TN and persistent idiopathic facial pain (PIFP). The significance of clinical symptoms and the type of neurovascular compression (NC) are investigated in respect of the postoperative success and recurrent symptoms. METHODS AND RESULTS: MRA was performed in 310 consecutive patients with TN and PIFP. The MRA image was positive in 179 (58%) of the 310 cases. 68.2% of the typical TN group, 49.2% of the atypical TN group and 3.2% of the PIFP group were positive. MVD was performed in 116 of the MRA positive cases. Four years following the MVD, 69% of the patients gave an excellent and 23% a good result. The surgical findings corresponded with the MRA images. NC could be ruled out in the background of PIFP. The rate of recurrent symptoms following MVD is 21% in the typical TN group while it is 41% in the atypical TN group. The pure venous compression showed 57% pain-recurrence rate following MVD. CONCLUSIONS: The clinical symptoms and preoperative MRA carry considerable information, which can predict the outcome of the MVD and the rate of recurrent symptoms. Atypical TN and venous compression are bad prognostic factors.