Ependimomas de fosa posterior de tipo lateral en la edad pediátrica / Lateral-type posterior fossa ependymomas in pediatric population

Antecedentes y objetivos: Los ependimomas de fosa posterior de tipo lateral son un subtipo clínico e histológico característico, con un pronóstico poco favorable. Su incidencia es baja y su manejo quirúrgico es particularmente complejo. El objetivo del presente trabajo es revisar nuestra serie de ependimomas de fosa posterior de tipo lateral y contrastar nuestros resultados con la literatura disponible. Materiales y métodos: Sobre una muestra de 30 ependimomas intervenidos en neurocirugía pediátrica en los últimos 10 años, se identifican 7 casos de ependimomas de tipo lateral de la fosa posterior. Sobre esta serie de casos se realiza un estudio descriptivo retrospectivo. Resultados: La edad media de nuestros pacientes al diagnóstico fue de 3,75 años. Seis se presentaron con hidrocefalia. El volumen tumoral medio al diagnóstico fue de 61cm3. En 6 casos se llevó a cabo una resección completa y en un caso una resección casi completa. Cinco pacientes precisaron de forma transitoria una traqueostomía y una gastrostomía. La media de seguimiento fue de 58 meses. Durante este tiempo se produjo un caso de recidiva que posteriormente evolucionó a muerte. Cuatro casos de hidrocefalia posquirúrgica precisaron una derivación ventriculoperitoneal de LCR y 2 casos fueron manejados con ventriculostomía endoscópica. En la última revisión en consulta 4 pacientes llevaban una vida normal y 2 mostraban una restricción leve de la actividad de acuerdo con la escala de Lansky. Conclusiones: El objetivo del tratamiento quirúrgico de los ependimomas de tipo lateral de fosa posterior es la resección completa. Los déficits asociados a la disfunción de los pares bajos en nuestra serie fueron muy frecuentes pero transitorios. La progresiva caracterización molecular de estos tumores puede identificar diferentes grupos de riesgo sobre los que dirigir de forma adecuada la intensidad de los tratamientos adyuvantes.(AU)

Background and aims: Lateral-type posterior fossa ependymomas are a well-defined subtype of tumors both clinically and pathologically, with a poor prognosis. Their incidence is low and surgical management is challenging. The objective of the present work is to review our series of lateral-tye posterior fossa ependymomas and compare our results with those of previous series. Materials and methods: Among 30 cases of ependymoma operated in our pediatric department in the last 10 years, we identified seven cases of lateral-type posterior fossa ependymomas. We then performed a retrospective, descriptive study. Results: Mean age of our patients was 3.75 years. Six cases presented with hydrocephalus. Mean tumor volume at diagnosis was 61cc. A complete resection was achieved in six cases and a near-total resection in one patient. Five patients transiently required a gastrostomy and a tracheostomy. Mean follow-up was 58 months. One case progressed along this period and eventually died. Four cases of hydrocephalus required a ventriculoperitoneal CSF shunt and two were managed with a third ventriculostomy. At last follow-up four patients carried a normal life and two displayed a mild restriction according to Lansky's scale. Conclusions: The aim of surgical treatment in lateral-type posterior fossa ependymomas is complete resection. Neurological deficits associated to lower cranial nerve dysfunction are common but transient. Deeper genetic characterization of these tumors may identify risk factors that guide stratification of adjuvant therapies.(AU)

Lateral-type posterior fossa ependymomas in pediatric population.

BACKGROUND: Lateral-type posterior fossa ependymomas are a well-defined subtype of tumours both clinically and pathologically, with a poor prognosis. Their incidence is low and surgical management is challenging. The objective of the present work is to review our series of lateral-tye posterior fossa ependymomas and compare our results with those of previous series. METHODS: Among 30 cases of ependymoma operated in our paediatric department in the last ten years, we identified seven cases of lateral-type posterior fossa ependymomas. We then performed a retrospective, descriptive study. RESULTS: Mean age of our patients was 3.75 years. 6 cases presented with hydrocephalus. Mean tumour volume at diagnosis was 61 cc. A complete resection was achieved in six cases and a near-total resection in one patient. 5 patients transiently required a gastrostomy and a tracheostomy. Mean follow-up was 58 months. One case progressed along this period and eventually died. 4 cases of hydrocephalus required a ventriculoperitoneal CSF shunt and two were managed with a third ventriculostomy. At last follow-up 4 patients carried a normal life and two displayed a mild restriction according to Lansky´s scale. CONCLUSIONS: The aim of surgical treatment in lateral-type posterior fossa ependymomas is complete resection. Neurological deficits associated to lower cranial nerve dysfunction are common but transient. Deeper genetic characterization of these tumours may identify risk factors that guide stratification of adjuvant therapies.

Lateral-type posterior fossa ependymomas in pediatric patients: a national collaborative study.

PURPOSE: To review a multicentric series of lateral-type posterior fossa ependymomas operated in the last ten years and to analyze the factors related to clinical evolution and tumor survival. METHODS: Descriptive, retrospective study. Active members of the Spanish Society of Pediatric Neurosurgery were invited to participate in this multicentric study. Clinical and radiological data were incorporated to an open database. The role of histologic grade, grade of resection, postoperative morbidities, and clinical follow-up was evaluated through bivariate associations (chi-square), Kaplan-Meier's curves (log-rank test), and multivariate analysis (binary logistic regression). RESULTS: Fourteen centers entered the study, and 25 cases with a minimum follow-up of 6 months were included. There were 13 boys and 12 girls with a mean age close to 3 years. Mean tumor volume at diagnosis was over 60 cc. A complete resection was achieved in 8 patients and a near-total resection in 5 cases. Fifteen tumors were diagnosed as ependymoma grade 2 and ten as ependymoma grade 3. Major morbidity occurred postoperatively in 14 patients but was resolved in twelve within 6 months. There were six cases of death and 11 cases of tumor progression along the observation period. Mean follow-up was 44.8 months. Major morbidity was significantly associated with histologic grade but not with the degree of resection. Overall and progression-free survival were significantly associated with complete surgical resection. At the last follow-up, 16 patients carried a normal life, and three displayed a mild restriction according to Lansky's scale. CONCLUSIONS: Lateral-type posterior fossa ependymomas constitute a specific pathologic and clinical tumor subtype with bad prognosis. Gross total resection is the goal of surgical treatment, for it significantly improves prognosis with no additional morbidity. Neurological deficits associated to lower cranial nerve dysfunction are common, but most are transient. Deeper genetic characterization of these tumors may identify risk factors that guide new treatments and stratification of adjuvant therapies.

CSF leak after pediatric endoscopic endonasal expanded approaches: a series review.

PURPOSE: Endoscopic endonasal approaches in the pediatric population pose specific challenges. Management of postoperative cerebrospinal fluid [CSF] leak is probably the major concern. The purpose of the present investigation is to describe and analyze the incidence of postoperative CSF leaks in our pediatric series of endoscopic endonasal approaches. METHODS: This is a retrospective analysis, case review of our institutional series. Descriptive statistical parameters and bivariate correlations are analyzed. RESULTS: Twenty-one patients have been operated through endoscopic approaches in our series. Four patients showed a postoperative CSF leak needing a revision surgery; these cases are described in further detail. Approaches expanded beyond the sellar area and non-sellar pneumatization of the sphenoid sinus were significantly associated with a higher risk of postoperative CSF leak. CONCLUSIONS: CSF leak incidence after endoscopic endonasal approaches is higher in pediatric patients than in adult series. Anatomic and pathologic factors add complexity to these approaches in children. Multilayer closure is advisable to prevent and treat this complication.

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.

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.

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.

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