Impact of Multilayer Vascularized Reconstruction after Skull Base Endoscopic Endonasal Approaches.

Background The use of vascularized flap to reconstruct the skull base defects has dramatically changed the postoperative cerebrospinal fluid (CSF) leak rates allowing the expansion of endoscopic skull base procedures. At present, there is insufficient scientific evidence to permit identification of the optimal reconstruction technique after the endoscopic endonasal approach (EEA). Objective The main purpose of this article is to establish the risk factors for failure in the reconstruction after EEA and whether the use of a surgical reconstruction protocol can improve the surgical results. Material and Methods A retrospective cohort study was conducted in our institution, selecting patients that underwent EEA with intraoperative CSF leak. Two reconstructive protocols were defined based on different reconstructive techniques; both were vascularized but one monolayer and the other multilayer. A multivariate analysis was performed with outcome variable presentation of postoperative leak. Results One hundred one patients were included in the study. Patients reconstructed with protocol 1, with the diagnosis different to the pituitary adenoma and older than 45 years old had higher risk of presenting postoperative leak, and with statistically significant differences when we adjusted for the remaining variables. Conclusion The vascularized reconstructions after endoscopic endonasal skull base approaches have demonstrated to be able to obtain a low rate of postoperative CSF leak. The multilayer vascularized technique may provide a more evolved technique, even reducing the postoperative leak rates comparing with the monolayer vascularized one. The reconstructive protocol employed in each case, as well as age and histological diagnosis, is independent risk factor for presenting postoperative leak.

Hemangiopericytoma/Solitary Fibrous Tumor in the central nervous system. Experience with surgery and radiotherapy as a complementary treatment: A 10-year analysis of a heterogeneous series in a single tertiary center / Hemangiopericitoma/tumor fibroso solitario en el sistema nervioso central. Experiencia con Cirugía y Radioterapia como tratamiento complementario: un análisis de 10 años sobre una serie heterogénea en un centro terciario

Hemangiopericytoma and Solitary Fibrous Tumor are tumors with low incidence. They have a tendency to recur locally and to metastasize. The WHO integrated both tumors into a new entity but one of the pending issues is to demonstrate the effectiveness of surgery plus complementary radiotherapy (RT) and standardize the use of it. We reviewed the data from 10 years. We assessed pathologic and radiologic characteristics. The operation records were evaluated to determine the features and extent of tumor resection. We compared the outcomes in patients using or not RT. The mean follow-up was 74.8 months, with a range of 12 and 210 months. The population included 3 males (30%) and 7 females (70%). The most common location was brain convexity (30%), the remaining were cervical and lumbar spine, sacrum, intraventricular, torcular, sphenoid ridge and intraorbital. Postoperative external beam radiotherapy was delivered in 7 patients (70%), the criteria were a partial resection or WHO II and III histological grades.2 patients developed local recurrences at 12 and 19 months after initial surgery.1 patient underwent 2 surgeries, and the other, 4 surgeries. The mean recurrence free survival rate was 15.5 months. Distant metastases were found in 4 PATIENTS: 3 of the 10 patients died. Five-year overall survival rate was 66% and mean overall survival was 76 months. A safe and complete resection in the first surgery is the most important prognostic factor.complementary RT can be helpful, even in cases of complete resection in WHO low-grade

El hemangiopericitoma y el tumor fibroso solitario son enfermedades del sistema nervioso central (SNC) con una incidencia baja. Estos tumores también pueden tener algunas características como una tendencia a recurrir localmente y hacer metástasis. La OMS, en su última clasificación de tumores del SNC, integró ambos tumores en una nueva entidad: tumor fibroso solitario/hemangiopericitoma (SFT/HPC), pero uno de los problemas actuales pendientes es demostrar la efectividad de la cirugía y la radioterapia (RT) complementaria, y estandarizar el uso de la misma. Revisamos todos los datos clínicos de nuestro hospital en un período de 10 años, y encontramos 10 pacientes con SFT/HPC. Se evaluaron los tamaños de los tumores, las ubicaciones y las características radiológicas. Los registros quirúrgicos de cada paciente se evaluaron para determinar las características macroscópicas y el alcance de la resección del tumor (EOR). También comparamos los resultados en los pacientes que utilizan o no RT como tratamiento complementario. El seguimiento medio fue de 74,8 meses, con un rango de 12 y 210 meses. La población incluía 3 varones (30%) y 7 mujeres (70%). La localización más frecuente fue la convexidad cerebral (30%). Las distribuciones de las localizaciones restantes del tumor fueron columna cervical y lumbar, sacro, intraventricular, torcular, ala esfenoidal e intraorbitario. La radioterapia postoperatoria (EBRT) se administró en 7 pacientes (70%), los criterios para tratarlos fueron una resección parcial o un grado histológico de la OMS II y III. Dos pacientes desarrollaron recidivas locales a los 12 y 19 meses después de la cirugía inicial. Un paciente se sometió a 2 cirugías, y el otro a 4 cirugías. La tasa media de supervivencia libre de recidiva (RFS) fue de 15,5 meses. Se encontraron metástasis a distancia en 4 pacientes durante el período de seguimiento. Tres de los 10 pacientes fallecieron durante el período de seguimiento. La tasa de supervivencia general a 5 años fue del 66%, y la supervivencia media global fue de 76 meses. Una resección segura y completa en la primera cirugía es el factor pronóstico más importante. Consideramos que la RT complementaria puede ser útil, incluso en casos de resección completa en SFT/HPC de bajo grado. Sería interesante definir previamente la diferenciación entre el SFT/HPC y los meningiomas para las estrategias de tratamiento

Hemangiopericytoma/Solitary Fibrous Tumor in the central nervous system. Experience with surgery and radiotherapy as a complementary treatment: A 10-year analysis of a heterogeneous series in a single tertiary center.

Hemangiopericytoma and Solitary Fibrous Tumor are tumors with low incidence. They have a tendency to recur locally and to metastasize. The WHO integrated both tumors into a new entity but one of the pending issues is to demonstrate the effectiveness of surgery plus complementary radiotherapy (RT) and standardize the use of it. We reviewed the data from 10 years. We assessed pathologic and radiologic characteristics. The operation records were evaluated to determine the features and extent of tumor resection. We compared the outcomes in patients using or not RT. The mean follow-up was 74.8 months, with a range of 12 and 210 months. The population included 3 males (30%) and 7 females (70%). The most common location was brain convexity (30%), the remaining were cervical and lumbar spine, sacrum, intraventricular, torcular, sphenoid ridge and intraorbital. Postoperative external beam radiotherapy was delivered in 7 patients (70%), the criteria were a partial resection or WHO II and III histological grades. 2 patients developed local recurrences at 12 and 19 months after initial surgery. 1 patient underwent 2 surgeries, and the other, 4 surgeries. The mean recurrence free survival rate was 15.5 months. Distant metastases were found in 4 patients. 3 of the 10 patients died. Five-year overall survival rate was 66% and mean overall survival was 76 months. A safe and complete resection in the first surgery is the most important prognostic factor. Complementary RT can be helpful, even in cases of complete resection in WHO low-grade.

Fully endoscopic transoral resection of high cervical osteophyte. How I do it?

BACKGROUND: Fully endoscopic transoral approaches (FETOA) constitute a reasonable option for the treatment of middling compressive pathology that involve the craniocervical junction and higher cervical levels. METHODS: We describe, step by step, the FETOA for the treatment of upper cervical lesions. More specifically, the ones that are located between C1 and C3. A giant anterior C1-C2 osteophyte resection will be used as an illustration of these approaches. CONCLUSIONS: This technique represents a minimally invasive treatment option for these kinds of high cervical lesions. It offers optimal visualization, maximizing the resection of these lesions and decreasing the morbidity and mortality.

Incomplete reossification after craniosynostosis surgery-incidence and analysis of risk factors: a clinical-radiological assessment study.

OBJECTIVE One of the principles of the surgical treatment of craniosynostosis includes the release of fused bone plates to prevent recurrence. Such bone defects require a reossification process after surgery to prevent a cosmetic problem or brain vulnerability to damage. The objective of this study is to describe and analyze the radiological and clinical evolution of bone defects after craniosynostosis. METHODS From January 2005 to May 2016, 248 infants underwent surgical correction of craniosynostosis at HUiP La Fe Valencia; the authors analyzed data from 216 of these cases that met the inclusion criteria for this study. Various surgical techniques were used according to the age of the patient and severity of the case, including endoscopic-assisted suturectomy, open suturectomy, fronto-orbital advancement, and cranial vault remodeling. Clinical follow-up and radiological quantitative measurements in 2 periods-12-24 months and 2 years after surgery-were analyzed; 94 patients had a postoperative CT scan and were included in the radiological analysis. RESULTS At the end of the follow-up period, 92 of 216 patients (42.59%) showed complete closure of the bone defect, 112 patients (51.85%) had minor bone defects, and 12 patients (5.56%) had significant bone defects that required surgical intervention. In the multivariate analysis, age at first surgery was not significantly associated with incomplete reossification (p = 0.15), nor was surgical site infection (p = 0.75). Multivariate analysis identified area of cranial defect greater than 5 cm2 in the first CT scan as predictive of incomplete reossification (p = 0.04). The mean area of cranial defect in the first CT scan (12-24 months after surgery) was 3.69 cm2 in patients treated with open surgery and 7.13 cm2 in those treated with endoscopic-assisted procedures; in the multivariate analysis, type of procedure was not related to incomplete reossification (p = 0.46). The positive predictive value of palpation as evaluation of bone cranial defects was 50% for significant defects and 71% for minor defects. CONCLUSIONS The incidence of cranial defects due to incomplete reossification requiring cranioplasty was 5.56% in our series. Defects greater than 5 cm2 in the first postoperative CT scan showed a positive association with incomplete reossification. Patients treated with endoscope-assisted procedures had larger defects in the initial follow-up, but the final incidence of cranial defects was not significantly different in the endoscope-assisted surgery group from that in the open surgery group.

Radiological Study of the Carotid-Clival Window and Its Application in Endoscopic Endonasal Expanded Approaches.

BACKGROUND: The surgical approach to the petrous apex (PA) and petroclival junction (PCJ) remains a challenge. The carotid-clival window (CCW) represents the widest window available to approach the PCJ from a mediolateral endoscopic route. Here we define the CCW radiologically in nonpathological conditions, to establish the anatomic variability of the PCJ, relate this variability to pneumatization patterns, and evaluate some technical concerns conditioned by the CCW. METHODS: This was an analytical study of 10 multislice computed tomography scans from patients without SB pathology. Bilateral measures were taken at the roof and floor levels of the lacerum canal (LC) and its posterior projection over the PCJ (segments DE and QR). All measures were compared across different pneumatization patterns. RESULTS: The DE and QR lengths were found to be the most important measures affecting the width of the CCW. Wide variability was observed, with a mean DE length of 8.52 mm (range, 2.4-12.8 mm) at the LC floor level and a mean QR length of 9.11 mm (range, 4.3-13.1 mm) at the LC roof level. The presence of retrocarotid pneumatization was statistically significantly associated with longer DE and QR segments. No differences were found among other pneumatization patterns. CONCLUSIONS: The CCW varies widely among individuals. The presence of pneumatization behind the paraclival carotid represents an advantageous characteristic when planning an endoscopic approach to the PCJ.

Endo ICG videoangiography: localizing the carotid artery in skull-base endonasal approaches.

BACKGROUND: In this work, the applicability of ICG-VA to skull base endoscopic surgery and its capacity to locate the internal carotid artery are shown. METHODS: An adapted optical module to perform ICG-VA was used to perform endoscopic procedures. There were two intraoperative phases of interest that were used to evaluate the ICA: upon exposure of the skull base and during the intradural exploration. This new tool for obtaining ICA images in real time (as opposed to with navigation), and it is demonstrated that this tool provides a superior ability to detect the margins of the ICA compared with the Doppler technique. On the other hand, the present technique also provides enhancement of the artery through the bone of the skull base without the need for drilling. CONCLUSIONS: ICG-VA is a safe and effective technique for locating the ICA in skull-base expanded endonasal surgery. Furthermore, this technique can provide real-time guidance for the surgeon and increase safety for the patient.

Indocyanine Green Videoangiography in Negative: Spinal Dural Arteriovenous Fistula.

Introduction This work reports the first indocyanine green videoangiography (IGV) in negative published with video format support. This technique, so called because its first phase is performed with occlusion of the vessel suspected of being pathologic, is used for the diagnosis of spinal arteriovenous fistula (sDAVF). Case Report The authors present the case of a 68-year-old man with an sDAVF fed by the right T7 segmentary artery. IGV was initially performed with the presumptive fistula feeder occluded for less than 1 minute, which provided both diagnostic and postexclusion control in one procedure. This technique therefore is reversible by not prolonging vascular exclusion times. Discussion IGV in negative is an extremely visual and intuitive procedure that represents an improvement over conventional IGV. Conclusion Studies with larger sample sizes are necessary to determine whether IGV in negative can further reduce the need for postoperative digital subtraction angiography.

Indocyanine green videoangiography methodological variations: review.

Indocyanine green videoangiography (ICGVA) procedures have become widespread within the spectrum of microsurgical techniques for neurovascular pathologies. We have conducted a review to identify and assess the impact of all of the methodological variations of conventional ICGVA applied in the field of neurovascular pathology that have been published to date in the English literature. A total of 18 studies were included in this review, identifying four primary methodological variants compared to conventional ICGVA: techniques based on the transient occlusion, intra-arterial ICG administration via catheters, use of endoscope system with a filter to collect florescence of ICG, and quantitative fluorescence analysis. These variants offer some possibilities for resolving the limitations of the conventional technique (first, the vascular structure to be analyzed must be exposed and second, vascular filling with ICG follows an additive pattern) and allow qualitatively superior information to be obtained during surgery. Advantages and disadvantages of each procedure are discussed. More case studies with a greater number of patients are needed to compare the different procedures with their gold standard, in order to establish these results consistently.

Microscopic versus endoscopic pituitary surgery / Cirugía hipofisaria microscópica versus endoscópica

INTRODUCTION AND OBJECTIVE: The endoscopic techniques used in pituitary surgery have evolved greatly in recent years. Our objective in this study was to conduct a review of the systematic reviews published in the English language literature, to examine their consistency and conclusions reached following studies comparing microsurgery and endoscopic surgery in hypophyseal surgery. MATERIALS AND METHODS: We carried out a bibliographic search on MEDLINE and EMBASE electronic databases, selecting those systematic reviews and meta-analyses published from the year 2000 until January 2013, focusing on comparisons between microsurgical and endoscopic techniques. RESULTS: We concluded with type A consistency that hospital stay was shorter and diabetes insipidus and rhinological complications were less frequent in the endoscopy group. We concluded with type B consistency that lower rates of patient blood loss, shorter operative times, higher rate of gross total resection, lesser association to visual impairment and lower rate of hypopituitarism were observed in the endoscopy group. Vascular complications and cerebrospinal fluid fistulas were reduced with microsurgery. It is crucial to perform a combined analysis of all the systematic reviews treating a specific topic, observing and analysing the trends and how these are affected by new contributions. CONCLUSION: Randomized multicenter studies are necessary to resolve the controversy over endoscopic and microsurgical approaches in hypophyseal pathology

INTRODUCCIÓN Y OBJETIVO: Las técnicas endoscópicas aplicadas a la cirugía hipofisaria han experimentado un importante desarrollo en los últimos años. Nuestro objetivo es realizar un examen de las diferentes revisiones sistemáticas publicadas en la literatura inglesa, para determinar la consistencia y las conclusiones alcanzadas tras la comparativa entre abordajes endoscópicos y microscópicos en la cirugía hipofisaria. MATERIAL Y MÉTODOS: Se ha realizado una revisión de la literatura inglesa utilizando las bases de datos MEDLINE y EMBASE, seleccionando las revisiones sistemáticas y metaanálisis publicados desde el año 2000 al 2013, focalizándonos en la comparativa entre los abordajes endoscópicos y microscópicos para el tratamiento de patología hipofisaria. RESULTADOS: Concluimos con consistencia tipo A que la estancia hospitalaria fue más corta, así como la diabetes insípida y las complicaciones rinológicas fueron menos frecuentes en el grupo endoscópico. Encontramos consistencia tipo B a favor de que la pérdida hemática es menor, el tiempo quirúrgico es más corto, la tasa de resección completa es mayor, el deterioro visual es menos frecuente y la tasa de hipopituitarismo es menor en el grupo endoscópico. Las complicaciones vasculares y la fístula de LCR fueron menos frecuentes en el grupo microscópico con consistencia tipo B. Resulta fundamental realizar un análisis combinado de todas las revisiones sistemáticas que tratan un tema específico, observando y analizando las tendencias y cómo estas se pueden ver afectadas por las nuevas contribuciones. CONCLUSIONES: Estudios aleatorizados multicéntricos son necesarios para resolver la controversia entre el tratamiento endoscópico y microscópico de la patología hipofisaria

Full endoscopic endonasal transclival approach: Meningioma attached to the ventral surface of the brainstem

BACKGROUND: Intracranial meningiomas without dural attachment (MWODA) are rare entities. We present the first case published, to the best of our knowledge, regarding a MWODA attached to the ventral surface of the brainstem. This location makes the patient subsidiary to treatment through an expanded endonasal transclival approach. CLINICAL PRESENTATION: A 16-year-old female with suspected diagnosis of recurrence of a clear cell meningioma (CCM) at a distance from the initial lesion, located on the premedullary cistern. The patient underwent a pure endoscopic low transclival approach. The attachment to the ventral surface of the brainstem was confirmed intraoperatively. Postoperative MRI confirmed gross total resection and treatment was complemented with adjuvant fractionated stereotactic radiotherapy. No complications related to the procedure were observed. CONCLUSION: MWODA may appear attached to the ventral brainstem. The expanded endonasal approach to the clivus provides a critical anatomical advantage in the treatment of medial lesions, even ventral meningiomas, to the lower cranial nerves. Reconstruction principles must be strictly respected to reduce complications

INTRODUCCIÓN: Los meningiomas sin implantación dural MSID son una rara entidad. Presentamos el primer caso publicado en nuestro conocimiento, de MSID implantado en la superficie ventral del tronco cerebral. Dicha localización permite la realización de un abordaje quirúrgico endonasal expandido transclival para su tratamiento. CASO CLÍNICO: Paciente mujer de 16 años con la sospecha de presentar una recurrencia de meningioma de células claras localizada en la cisterna prebulbar a distancia de la lesión inicialmente tratada. Se llevó a cabo un abordaje endonasal expandido transclival. El hallazgo de implantación en la cara ventral del tronco cerebral fue claramente evidenciado en el acto quirúrgico. La RM cerebral postoperatoria confirmó la resección completa y el tratamiento fue completado con radioterapia estereotáctica fraccionada. No se presentaron complicaciones relacionadas con los procedimientos. CONCLUSIÓN: Los MSID pueden presentarse en íntima relación con la cara ventral del tronco cerebral. El abordaje endonasal expandido transclival otorga ventajas anatómicas importantes a la hora de tratar lesiones de localización medial, incluso meningiomas ventrales a los pares craneales bajos. Las técnicas reconstructivas deben ser estrictamente respetadas para minimizar complicaciones

Full endoscopic endonasal transclival approach: meningioma attached to the ventral surface of the brainstem.

BACKGROUND: Intracranial meningiomas without dural attachment (MWODA) are rare entities. We present the first case published, to the best of our knowledge, regarding a MWODA attached to the ventral surface of the brainstem. This location makes the patient subsidiary to treatment through an expanded endonasal transclival approach. CLINICAL PRESENTATION: A 16-year-old female with suspected diagnosis of recurrence of a clear cell meningioma (CCM) at a distance from the initial lesion, located on the premedullary cistern. The patient underwent a pure endoscopic low transclival approach. The attachment to the ventral surface of the brainstem was confirmed intraoperatively. Postoperative MRI confirmed gross total resection and treatment was complemented with adjuvant fractionated stereotactic radiotherapy. No complications related to the procedure were observed. CONCLUSION: MWODA may appear attached to the ventral brainstem. The expanded endonasal approach to the clivus provides a critical anatomical advantage in the treatment of medial lesions, even ventral meningiomas, to the lower cranial nerves. Reconstruction principles must be strictly respected to reduce complications.

Microscopic versus endoscopic pituitary surgery.

INTRODUCTION AND OBJECTIVE: The endoscopic techniques used in pituitary surgery have evolved greatly in recent years. Our objective in this study was to conduct a review of the systematic reviews published in the English language literature, to examine their consistency and conclusions reached following studies comparing microsurgery and endoscopic surgery in hypophyseal surgery. MATERIALS AND METHODS: We carried out a bibliographic search on MEDLINE and EMBASE electronic databases, selecting those systematic reviews and meta-analyses published from the year 2000 until January 2013, focusing on comparisons between microsurgical and endoscopic techniques. RESULTS: We concluded with type A consistency that hospital stay was shorter and diabetes insipidus and rhinological complications were less frequent in the endoscopy group. We concluded with type B consistency that lower rates of patient blood loss, shorter operative times, higher rate of gross total resection, lesser association to visual impairment and lower rate of hypopituitarism were observed in the endoscopy group. Vascular complications and cerebrospinal fluid fistulas were reduced with microsurgery. It is crucial to perform a combined analysis of all the systematic reviews treating a specific topic, observing and analysing the trends and how these are affected by new contributions. CONCLUSION: Randomized multicenter studies are necessary to resolve the controversy over endoscopic and microsurgical approaches in hypophyseal pathology.

Metástasis sacra simulando quiste óseo aneurismático / Sacral metastasis simulating aneurysmal bone cyst

El hallazgo de lesiones raquídeas quísticas con patrones característicos, como la presencia de niveles serohemáticos líquido-líquido (NSL-L), se ha relacionado con multitud de estirpes tumorales, asociándose con mayor frecuencia al quiste óseo aneurismático (QOA) y de forma extraordinaria a metástasis. En este artículo presentamos el caso de un varón de 60 años de edad con el hallazgo de una lesión ósea quística sacra y NSL-L, inicialmente orientado hacia el diagnóstico de QOA, con diagnóstico definitivo de metástasis. El caso presentado es, en nuestro conocimiento, el segundo caso publicado de metástasis ósea quística raquídea con NSL-L sin tumor primario conocido en el momento del diagnóstico y el único que recibió tratamiento quirúrgico con fin resectivo, alcanzando control de la enfermedad metastásica y pulmonar con una adecuada calidad de vida tras un año de seguimiento

Cystic spinal lesions with characteristic patterns, such as the presence of haematic fluid levels (H-FFL), have been associated with many tumoral lineages, more frequently with aneurysmal bone cyst (ABC) and exceptionally with metastasis. We present the case of a60-year-old man with the finding of a sacral cystic bone lesion with H-FFL, with initial suspicion of ABC and confirmed diagnosis of metastasis. The case presented is, to our knowledge, the second case published of spinal cystic bone metastasis with H-FFL pattern with unknown primary tumour at the time of diagnosis and the only one that received resective surgical treatment, achieving pulmonary and metastatic disease control with good quality of life after 1 year of follow up

[Sacral metastasis simulating aneurysmal bone cyst]. / Metástasis sacra simulando quiste óseo aneurismático.

Cystic spinal lesions with characteristic patterns, such as the presence of haematic fluid-fluid levels (H-FFL), have been associated with many tumoral lineages, more frequently with aneurysmal bone cyst (ABC) and exceptionally with metastasis. We present the case of a 60-year-old man with the finding of a sacral cystic bone lesion with H-FFL, with initial suspicion of ABC and confirmed diagnosis of metastasis. The case presented is, to our knowledge, the second case published of spinal cystic bone metastasis with H-FFL pattern with unknown primary tumour at the time of diagnosis and the only one that received resective surgical treatment, achieving pulmonary and metastatic disease control with good quality of life after 1 year of follow up.

Endoscopia endonasal de base de cráneo / Endonasal skull base endoscopy

INTRODUCCIÓN Y OBJETIVO: Las técnicas endoscópicas aplicadas a la base de cráneo han experimentado un fulgurante avance en los últimos años. Este trabajo plantea como objetivo la revisión sistemática de, a su vez, las revisiones sistemáticas publicadas en la literatura inglesa, para examinar las conclusiones y las evidencias halladas en los estudios que comparan cirugía abierta frente a endoscópica de base de cráneo. MATERIAL Y MÉTODOS: Se ha realizado una revisión sistemática cualitativa en las bases de datos MEDLINE y EMBASE de la literatura inglesa disponible desde el año 2000, seleccionando las revisiones sistemáticas, metaanálisis y revisiones de medicina basada en la evidencia de las diferentes patologías de la base de cráneo, focalizándonos en el impacto de la cirugía endoscópica y en la comparativa entre los abordajes endonasales endoscópicos y transcraneales. RESULTADOS: Los abordajes endoscópicos endonasales han alcanzado tasas de resección completa de craneofaringiomas y cordomas, superior a los abordajes transcraneales clásicos. Respecto a los meningiomas de fosa craneal anterior, los abordajes transcraneales consiguen una tasa de resección completa mayor que los abordajes endoscópicos con una tendencia favorable a la endoscopia, en cuanto a pronóstico visual. Los abordajes endoscópicos han alcanzado minimizar las complicaciones postoperatorias en el tratamiento de las fístulas de líquido cefalorraquídeo (LCR), encefaloceles, meningoceles, craneofaringiomas y cordomas, salvo la fístula de LCR postoperatoria. CONCLUSIONES: Estudios de mayor evidencia deben ser planteados para establecer de forma definitiva las posibles diferencias entre abordajes endonasales endoscópicos y transcraneales

INTRODUCTION AND OBJECTIVE: The endoscopic endonasal techniques used in skull base surgery have evolved greatly in recent years. Our study objective was to perform a qualitative systematic review of the likewise systematic reviews in published English language literature, to examine the evidence and conclusions reached in these studies comparing transcranial and endoscopic approaches in skull base surgery. MATERIAL AND METHODS: We searched the references on the MEDLINE and EMBASE electronic databases selecting the systematic reviews, meta-analyses and evidence based medicine reviews on skull based pathologies published from January 2000 until January 2013. We focused on endoscopic impact and on microsurgical and endoscopic technique comparisons. RESULTS: Full endoscopic endonasal approaches achieved gross total removal rates of craniopharyngiomas and chordomas higher than those for transcranial approaches. In anterior skull base meningiomas, complete resections were more frequently achieved after transcranial approaches, with a trend in favour of endoscopy with respect to visual prognosis. Endoscopic endonasal approaches minimised the postoperative complications after the treatment of cerebrospinal fluid (CSF) leaks, encephaloceles, meningoceles, craniopharyngiomas (..) (AU)

[Endonasal skull base endoscopy]. / Endoscopia endonasal de base de cráneo.

INTRODUCTION AND OBJECTIVE: The endoscopic endonasal techniques used in skull base surgery have evolved greatly in recent years. Our study objective was to perform a qualitative systematic review of the likewise systematic reviews in published English language literature, to examine the evidence and conclusions reached in these studies comparing transcranial and endoscopic approaches in skull base surgery. MATERIAL AND METHODS: We searched the references on the MEDLINE and EMBASE electronic databases selecting the systematic reviews, meta-analyses and evidence based medicine reviews on skull based pathologies published from January 2000 until January 2013. We focused on endoscopic impact and on microsurgical and endoscopic technique comparisons. RESULTS: Full endoscopic endonasal approaches achieved gross total removal rates of craniopharyngiomas and chordomas higher than those for transcranial approaches. In anterior skull base meningiomas, complete resections were more frequently achieved after transcranial approaches, with a trend in favour of endoscopy with respect to visual prognosis. Endoscopic endonasal approaches minimised the postoperative complications after the treatment of cerebrospinal fluid (CSF) leaks, encephaloceles, meningoceles, craniopharyngiomas and chordomas, with the exception of postoperative CSF leaks. CONCLUSIONS: Randomized multicenter studies are necessary to resolve the controversy over endoscopic and microsurgical approaches in skull base surgery.