"Tailored" approach to selected recurrent cranio-cervical chordomas: experience and lessons learned.

BACKGROUND: Among chordoma patients, recurrent cases are by far more complex to be managed, and cranio-cervical junction (CCJ) localizations represent a particular challenge due to the complexity of the anatomical region which makes it difficult to obtain a radical resection. METHODOLOGY: We report our personal experience in treating four patients with recurrent CCJ chordoma with "personalized" multiportal and eventually multistage approaches. CONCLUSIONS: Endoscopic endonasal approaches have gained widespread acceptance and are considered the workhorse in most cases of craniocervical junction chordomas. Nonetheless, in some cases of recurrence, or in presence of very lateralized lesions/ anatomical variations midline approaches are either contraindicated or very difficult to perform. In all these cases it seems reasonable to consider a versatile strategy including different approaches, modulating the surgical needs with different answers and solutions offered by the different routes. In other words to personalize as much as possible the approach, being creative and not dogmatic.

Comparison of a purely endoscopic three-layer technique versus pericranial flap for reconstruction of anterior skull base defects after sino-nasal tumor resection: assessment of postoperative frontal lobe sagging and frontal lobe falling.

BACKGROUND: The evolution of endoscopic skull base approaches has enabled surgeons to manage selected skull base tumors through a transnasal endoscope-assisted approach. On the other side, more extensive lesions may require a combined cranioendoscopic approach. In this paper, we analysed and compared the incidence of frontal lobe sagging after endoscopic multilayer (EM) reconstruction versus pericranial flap (PF) reconstruction. METHODOLOGY: Subjects were selected retrospectively according to specific inclusion and exclusion criteria. The degree of frontal lobe sagging after surgery was calculated based on the most inferior position of the frontal lobe relative to the nasion-sellar line defined on preoperative and postoperative imaging. A positive value signified upward displacement, and a negative value represented frontal lobe sagging. RESULTS: Twenty subjects were enrolled in our study. In the EM technique group the average frontal lobe displacement was -2,34 ± 1,55 mm. The average postoperative frontal lobe sagging was -0,45 ± 8,92 mm in subjects reconstructed with the PF. The skull base defect size correlated with the degree of frontal lobe sagging in subjects reconstructed with the PF, but not in the other group and when merging the two groups. CONCLUSIONS: In conclusion, the EM technique and the PF reconstruction showed a good reliability for the closure of anterior skull base defects. Moreover the PF seemed to prevent frontal lobe sagging but, for larger skull base defects, it could be useful to be combined with other autologous or heterologous materials to avoid the frontal lobe falling.