Septal rhinopharyngeal flap: a novel technique for skull base reconstruction after endoscopic endonasal clivectomies.

Endoscopic endonasal reconstruction techniques have improved CSF leak rates that were initially reported after surgery for cranial base and intradural lesions. However, wide surgical defects still pose a problem, especially if located in the clival region. The authors propose and describe a novel reconstruction technique they call a septal rhinopharyngeal flap (SRF) specifically designed to address this issue. The SRF is formed by three components of mucosa: 1) septal, 2) rhinopharyngeal roof, and 3) rhinopharyngeal posterior wall components, which allows for the coverage of the tuberculum/sellar region, midclivus, and lower clivus, respectively. A step-by-step procedure is described and its results analyzed in cases in which it has been used. The SRF was performed in 8 patients, which included diagnoses of 4 chordomas, 2 petroclival meningiomas, 1 invasive pituitary adenoma, and 1 chondrosarcoma. The size of the flap was considered optimal in all patients (100%). Postoperative MRI revealed contrast enhancement covering the entire surface of the flap. No CSF leaks were encountered after at least 1 postoperative year. The SRF is a novel vascularized reconstruction technique specifically indicated for wide endosanasal clivectomies focused on the middle clivus with caudal extension into the lower clivus and craniocervical junction, as well as rostral extensions into the tubercular or planum sphenoidale. This new reconstruction technique could be added to the skull base reconstruction armamentarium as a safe and optimal option.

Endonasal Odontoidectomy in Basilar Invagination.

Objective The endoscopic endonasal odontoidectomy (EEO) is emerging as a feasible surgical alternative to conventional microscopic transoral approach. In this article, we show EEO in the basilar invagination (BI) and describe in detail the technical aspects, advantages, and disadvantages of this approach ( Fig. 1 ). Methods We describe EEO using audiovisual material from the neurosurgical department of Hospital Universitari i Politècnic La Fe Valencia database. Results We present the case of a 61-year-old male patient with BI. Initially, we performed suboccipital decompression and occipitocervical fusion. Subsequently, after a no significant neurological improvement and persistent anterior compression, EEO was performed. The postoperative evolution was uneventful and the preoperative neurological deficits were recovered rapidly after surgery Discussion EEO technique enables complete odontoid resection, preventing invasion of aggressive oral bacterial flora, and it is not limited by the mouth opening. As well, it avoids manipulation of the soft palate, therefore evades the risk of velopalatal insufficiency, facilitates immediate oral tolerance, and early extubation. The rostral position of C1-C2 complex in BI could suppose a great advantage in favor the endonasal approaches. Mucoperichondrial vascularized flaps could be obtained to avoid a postoperative cerebrospinal fluid (CSF) leak and facilitate the reepithelization process of the surgical bed. Conclusion EEO may provide a significant anatomic and technical advantage over the trans-oral approach. The link to the video can be found at: https://youtu.be/Td6MDcjCNKk .

Spontaneous CSF rhinorrhea as a presenting symptom of a clival chordoma / Fístula espontánea de LCR como síntoma de presentación de un cordoma de clivus

CSF rhinorrhea is a rare presenting symptom of a clival chordoma as these tumors do not tend to show dural invasion as a histological feature. Here we discuss the case of a 61 years old female with spontaneous rhinorrhea secondary to a clival chordoma, and the value of some specific MRI sequences in accurate identification of a tumor with such atypical presentation, enabling the surgeon to plan accordingly (AU)

Los cordomas de clivus en muy raras ocasiones se presentan como fístulas espontáneas del líquido cefalorraquídeo, ya que estos tumores no suelen invadir el plano dural. Se presenta el caso de una paciente de 61 años con rinolicuorrea espontánea secundaria a un cordoma de clivus, haciendo énfasis en secuencias específicas de resonancia magnética para la correcta identificación de un tumor con una manifestación inicial tan atípica, permitiendo una planificación quirúrgica adecuada (AU)

Spontaneous CSF rhinorrhea as a presenting symptom of a clival chordoma.

CSF rhinorrhea is a rare presenting symptom of a clival chordoma as these tumors do not tend to show dural invasion as a histological feature. Here we discuss the case of a 61 years old female with spontaneous rhinorrhea secondary to a clival chordoma, and the value of some specific MRI sequences in accurate identification of a tumor with such atypical presentation, enabling the surgeon to plan accordingly.

Gangliogliomas in the pediatric population.

BACKGROUND: Gangliogliomas are neoplastic lesions composed by a mixed population of neoplastic glial and dysplastic neural cells. They represent around 5% of all CNS tumors in the pediatric population. These usually are well-differentiated, slow-growing tumors, meaning that complete resection could cure most of these patients. Although most lesions remain stable over time after incomplete resection, some patients develop progression of the residual lesions: the optimal approach to treat these tumors is still to be defined. METHODS: This is a retrospective study in which we obtained data from medical records of pediatric patients who had a histological diagnosis of ganglioglioma following surgical treatment at a single center between 2001 and 2020. RESULTS: We included 17 pediatric subjects with gangliogliomas. The median age at diagnosis was 6.7 years, and the median follow-up duration was 60 months. The most common clinical presentation was epileptic seizures (41.1%). Hydrocephalus was present in 29.4% of cases. 52.9% of tumors involved exclusively the cerebral hemispheres, with the temporal lobe being the most affected location. Gross total tumor resection (GTR) was accomplished in 47% of all cases and in 75% of hemispheric tumors. Of patients, 33% in whom GTR could not be achieved showed progression of the residual tumor. BRAF V600E mutation was present in 44.4% of cases. CONCLUSION: Gangliogliomas are typically grade I tumors that occasionally affect children. They classically localize in the cerebral hemisphere but may involve deep structures like the basal ganglia, brain stem, and cerebellum, which seems to be particularly frequent in the pediatric population, implying further challenge to achieve adequate oncological control with surgery as the only treatment modality. Although most cases in which GTR could not be performed remained stable over the follow-up, significant progression of the tumor remains was observed in some patients. BRAF inhibitors should be considered as a feasible treatment option in this setting.

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.

Laparoscopy-assisted placement of a ventriculobiliary shunt: a technical note.

PURPOSE: Hydrocephalus is a common condition in pediatric neurosurgeon's clinical practice. Peritoneal and atrial shunting is the treatment of choice in the immense majority of patients. Sometimes, there are complex cases that may need innovative solutions in order to implant the distal catheter of the shunt: in these situations, the gallbladder is a well-described option and it can be safely used. METHODS: We report the case of a 4-month-old baby with a wide optic-chiasmal hypothalamic glioma generating hydrocephalus with high protein values in CSF. Ventriculobiliary shunting was decided, and the distal catheter was directed by the assistance of laparoscopic surgery. RESULTS: The outcome was satisfactory. CONCLUSIONS: As far as we know, laparoscopic placement of a distal catheter in the gallbladder has not been described in the literature; herein, we describe the tenets and the technical tips of this approach.

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.

Transantral endoscopic approach for the treatment of lesions affecting the maxillary nerve.

BACKGROUND: Surgical approaches to skull base lesions that affect the maxillary nerve are complex, due to deep location and presence of relevant neurovascular structures surrounding this area. METHOD: We propose the transantral endoscopic approach (TEA) for the treatment of lesions affecting the maxillary nerve or its vicinity. More specifically, the ones that are located anterior to the foramen rotundum. CONCLUSIONS: This technique represents a minimally invasive treatment option for these kind of cranial base lesions. It offers optimal visualisation similar to the endonasal approach, whereas less dissection is required.

Full endoscopic endonasal transsellar-transclival approach: the modularity concept.

BACKGROUND: Endoscopic endonasal approaches (EEAs) constitute a reasonable option for the treatment of lesions that involve the sellar and clival regions. METHODS: We describe, step by step, the full EEA expanded to the middle and lower clivus for the treatment of perisellar lesions. Delimiting different modules around the sellar region is useful in establishing the best endoscopic approach for each tumor. A craniopharyngioma (CP) with clival extension will be used as an illustrative example of the modularity concept of these approaches. CONCLUSIONS: Transsellar-transclival EEA allows complete resection of lesions located in the sellar and infrasellar region with a low rate of complications.

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.

Brain abscess as the initial presentation of a macroprolactinoma: Case report

Los macroprolactinomas pueden ser invasivos e infiltrar la base del cráneo causando el posterior adelgazamiento que puede conducir a un defecto del hueso y una vía de entrada para patógenos. Describimos un varón de 34 años que ingresó en el hospital con cefalea, rigidez de nuca, diplopia y deterioro neurológico. Las imágenes de resonancia magnética nuclear mostraron dos abscesos bilaterales frontoparietales con trombosis venosa del seno y un adenoma hipofisario que se extendía desde la región supraselar, erosionando el suelo de la silla hacia el seno esfenoidal. El análisis hormonal mostró aumento del nivel de prolactina y descenso de los niveles de FSH, LH y testosterona. El paciente recibió tratamiento antibiótico y fue intervenido quirúrgicamente. El paciente desarrolló sordera central como déficit neurológico. Es recomendable incluir el adenoma hipofisario en el diagnóstico diferencial de la meningitis aunque su debut como abscesos intracraneales y trombosis del seno recto es extraordinario

Macroprolactinomas may behave invasively and infiltrate the skull base, causing a subsequent thinning that can also lead to a bone defect and a direct route of entry for pathogens. We describe the case of a 34-year-old male admitted to hospital with fever (38 ◦C), headache, stiffness in the neck, diplopia and neurological impairment. Brain magnetic resonance imaging showed two bilateral abscesses in the fronto-parietal areas with intracranial venous sinus thrombosis and a pituitary adenoma that extended from the suprasellar region, eroding the sellar floor into the sphenoid sinus. Laboratory hormone measurements showed increased levels of prolactin and low levels of FSH, LH and testosterone. The patient received antibiotic treatment and surgery was performed. The patient developed central deafness as a neurological deficit. It is advisable to include pituitary adenoma in the differential diagnosis of meningitis even though its onset as intracranial abscess and rectus sinus thrombosis is extremely rare

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.

Brain abscess as the initial presentation of a macroprolactinoma: Case report.

Macroprolactinomas may behave invasively and infiltrate the skull base, causing a subsequent thinning that can also lead to a bone defect and a direct route of entry for pathogens. We describe the case of a 34-year-old male admitted to hospital with fever (38°C), headache, stiffness in the neck, diplopia and neurological impairment. Brain magnetic resonance imaging showed two bilateral abscesses in the fronto-parietal areas with intracranial venous sinus thrombosis and a pituitary adenoma that extended from the suprasellar region, eroding the sellar floor into the sphenoid sinus. Laboratory hormone measurements showed increased levels of prolactin and low levels of FSH, LH and testosterone. The patient received antibiotic treatment and surgery was performed. The patient developed central deafness as a neurological deficit. It is advisable to include pituitary adenoma in the differential diagnosis of meningitis even though its onset as intracranial abscess and rectus sinus thrombosis is extremely rare.

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 suprapetrous approach to Meckel's cave.

BACKGROUND: Meckel's cave is an anatomically complex region that can be approached surgically via several routes, namely the posterolateral, lateral, anterolateral, and, due to recent advancements, anteromedial routes, with the latter being represented by the expanded endonasal approaches. METHOD: We describe in detail the surgical technique of the suprapetrous endonasal approach to Meckel's cave and highlight the main anatomical key elements involved in this approach as well as the technical aspects for avoiding surgical complications. CONCLUSION: The suprapetrous endonasal approach to Meckel's cave avoids the brain tissue retraction, and thereby prevents postoperative brain edema.

Full endoscopic endonasal expanded approach to the petroclival region: optimizing the carotid-clival window.

BACKGROUND: The petroclival junction (PCJ) is a challenging skull base location from neurosurgical point of view, especially if the retrocarotid space has to be reached. METHOD: In response to this challenge, this report provides a detailed full description of the endoscopic endonasal expanded approach (EEA) to the petroclival region and retrocarotid space. We present the technique step by step, introducing a critical concept about the optimization of the petroclival drilling, generating the carotid-clival window (CCW). The CCW is delimited by the paraclival segment of the internal carotid artery ICA anterolaterally, the petrous bone posterolaterally, the clival dura medially, the synchondrosis inferiorly, and the cavernous sinus superiorly; therefore, this approach exposes an important nuance to augment the previous approaches for PCJ and retrocarotid space. CONCLUSION: This technique provides a good surgical window and carries minimal risk.

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.