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2.
Artigo em Chinês | MEDLINE | ID: mdl-33472297

RESUMO

Objective: To evaluate the feasibility of the endoscopic transnasal approach (ETA) and to analyze the outcomes and factors of this surgical technique in the management of the tumor invading the anterior skull base. Methods: A retrospective analysis was performed on 42 patients (31 males and 11 females, with mean age of 49 years) with sinonasal tumor invading the anterior skull base, who underwent ETA from June 2015 to April 2019 in Eye, Ear, Nose and Throat Hospital of Fudan University. Pathologically, there were 15 cases of squamous carcinoma (14 patients with T4bN0M0 and 1 patient with T4bN1M0) and 27 of olfactory neuroblastomas with Kadish stage C. Anterior skull base reconstruction was performed using the vascular pedicled nasoseptal mucoperiosteal flap and fascia lata. Brain non-contrast-enhanced CT was performed on the first postoperative day to exclude massive pneumocephalus, relevant brain edema and subarachnoid hemorrhage. Sinonasal contrast-enhanced MR was performed to assess the extent of the tumor removal. Kaplan-Meier analysis was used to calculate the overall survival (OS) and Cox multivariate regression analysis was used to determine the prognostic factors. Results: The mean duration of the surgery was 452 minutes. Total resection was performed in 36 patients (85.7%), subtotal resection in 2 patients (4.8%) with orbital involvement, partial resection in one patient (2.4%) with injury of the internal carotid artery. One patient (2.4%) underwent the second resection because of the tumor residual, two patients (4.8%) with unsure tumor residual. Mean follow-up was 20 months, with 17 months of median follow-up. One-, two-and three-year overall survival was 86.5%, 76.9% and 64.5%, respectively. For squamous carcinoma, one-, two-and three-year overall survival was 86.2%, 86.2% and 57.4%, respectively. For olfactory neuroblastomas, One-, two-and three-year overall survival was 86.9%, 75.3% and 67.8%, respectively. Multivariate analysis showed that tumor residual (P=0.001) and recurrence (P<0.01) were independent prognostic factors for survival. Conclusions: The ETA is safe and feasible in selected patients with sinonasal tumor invading the anterior skull base. Tumor residual and recurrence are independent prognostic factors for survival.


Assuntos
Neoplasias Nasais , Neoplasias da Base do Crânio , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cavidade Nasal , Recidiva Local de Neoplasia , Neoplasias Nasais/cirurgia , Estudos Retrospectivos , Base do Crânio/cirurgia , Neoplasias da Base do Crânio/cirurgia
3.
Artigo em Chinês | MEDLINE | ID: mdl-33472300

RESUMO

Objective: To evaluate the application of combination use of endoscopic endonasal approach combined with the frontotemporal orbitozygomatic approach microscopically in skull base tumor with intra and extra-cranial involvement. Methods: A total of 7 patients (4 males and 3 females, aging from 27 to 65 years old, with a medium age of 48) undergone complicated skull base surgeries via endoscopic endonasal approach combined with the frontotemporal orbitozygomatic approach microscopically from May 2016 to January 2018 were reviewed respectively. The patients included 2 cases of recurrent invasive pituitary adenoma, 3 cases of basal skull meningiomas, 1 case of clivus chondrosarcoma, and 1 case of recurrent nasopharyngeal carcinoma. The lesion extensively infiltrated nasal cavity, extending to the paranasal sinus, bilateral cavernous sinus, sellar region, suprasellar, superior clivus, temporal lobe, pterygopalatine fossa, infratemporal fossa and important intracranial vessels. All the 7 patients were treated under general anesthesia by endoscopic endonasal approach combined with frontotemporal orbitozygomatic approach under the microscope. Total excision rate, intraoperative and postoperative complications and postoperative curative effect were observed. All of them were followed up for 6 to 12 months. The Glasgow Outcome Scale (GOS) was used to evaluate the prognosis. Result: Total tumor removal was performed in 5 cases, subtotal removel in 2 cases. There was no complication during the operation. Postoperative severe complications occurred in 2 cases, including 1 case of cerebrospinal fluid rhinorrhea and intracranial infection, which was cured by lumbar cistern drainage and intrathecal injection; 1 case occurred oculomotor nerve paralysis, which recovered during follow-up. Postoperative complications occurred in 1 case of trochlear nerve dysfunction, 2 cases of facial numbness, and 1 case of tinnitus. During follow-up, all patients recovered to varying degrees. There was no bleeding and death after the operation. No tumor recurred during the follow-up period. All patients were recovered well with GOS grade Ⅳ-Ⅴ. Conclusions: Endoscopic transnasal approach combined with microscopic frontotemporal orbitozygomatic approach can remove tumors in one stage, reduce surgical complications and improve surgical effect. It has good application prospects and is suitable for excising complex intracranial and extracranial communicating tumors of widely involving sellar, clivus and petrous apex area.


Assuntos
Neoplasias Meníngeas , Meningioma , Neoplasias da Base do Crânio , Adulto , Idoso , Endoscopia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fossa Pterigopalatina , Estudos Retrospectivos , Base do Crânio/cirurgia , Neoplasias da Base do Crânio/cirurgia
4.
Artigo em Chinês | MEDLINE | ID: mdl-33472305

RESUMO

Objective: To evaluate the value of Hadad-Bassagasteguy flap (HBF) in endoscopic endonasal approaches (EEA) skull base reconstruction by radioanatomic measurements on CT of the skull base of Chinese adults. The following data in terms of anterior skull base defect and reconstruction, sphenoid platform area and middle skull base defect and reconstruction including sphenoid platform and sella area, clivus area defect and reconstruction, and HBF were collected and assessed. Methods: CT image data of 42 Chinese adults were selected to obtain radioanatomic measurement data related to HBF, anterior skull base defect and reconstruction, middle skull base defect and reconstruction, and defect and reconstruction of clivus area. SPSS 26.0 software was used to analyze the data. Results: The radioanatomic measurement data about HBF and skull base of 42 Chinese adults were obtained. The width of the leading edge of HBF [(37.49±2.86) mm] was 6 mm more than the anterior skull base width at the level of the anterior ethmoidal artery [(30.87±8.61) mm], and the width of the trailing edge of HBF [(42.61±3.95) mm] was also 6 mm more than the anterior skull base width at the level of the sphenoethmoidal junction [(26.79±2.79) mm]. The total length of HBF including the pedicle [(79.68±4.96) mm] was 6 mm more than the length of the anterior skull base reconstruction [(54.06±8.67) mm], and the length of HBF without pedicle [(46.27±3.14)] mm was 6 mm more than the length of anterior skull base defect [(30.87±8.61) mm]. The trailing edge width was 6 mm more than the planum sphenoidal width at the level of the optic strut [(30.87±8.61) mm]. The total length of HBF including the pedicle was 6 mm more than the length of the planum sphenoidal, and the sella reconstruction [(64.44±10.25) mm], also was 6 mm more than the length of the planum sphenoidal reconstruction [(73.61±8.28) mm]. The length of HBF without pedicle was 6 mm more than the length of the planum sphenoidal, and the sella defect [(27.88±3.74) mm], also was 6 mm more than the length of the planum sphenoidal defect [(15.50±3.38) mm]. The width of the leading edge of HBF and the width of the trailing edge were both 6 mm more than the width of clivus reconstruction at the level of the foramen lacerum [(21.68±2.30) mm]. The total length of HBF including pedicles was 6 mm more than the clivus reconstruction length [(67.09±5.44) mm], while the length of HBF without pedicles was also 6 mm more than the clivus defect length [(37.19±3.80) mm]. Conclusions: In this study, the radiosanatomic measurements ensured that HBF could provide sufficient tissue flap for the reconstruction of the anterior skull base and sphenoid plateau and extend the reconstruction area to sella and clivus. Preoperative radiosanatomic measurement can be used to predict the size of HBF required for skull base reconstruction, which provides important guidance for flap harvest.


Assuntos
Procedimentos Cirúrgicos Reconstrutivos , Neoplasias da Base do Crânio , Adulto , Endoscopia , Humanos , Nariz/diagnóstico por imagem , Nariz/cirurgia , Base do Crânio/diagnóstico por imagem , Base do Crânio/cirurgia , Neoplasias da Base do Crânio/diagnóstico por imagem , Neoplasias da Base do Crânio/cirurgia , Osso Esfenoide , Retalhos Cirúrgicos
6.
J Cancer Res Ther ; 16(3): 668-671, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32719288

RESUMO

Chordomas are rare tumors which arise from the embryological remnants of the notochord. These tumors can potentially arise from any region within the craniospinal axis and often clinically present as a diagnostic challenge. Chordomas are rare in patients younger than 40 years of age. The most common primary cancers that metastasize to the jaw bones are the ones originating from the breast, lung, kidney adrenal, colo-rectum, or prostate. Mandibular metastasis from a primary chordoma is an extremely rare occurrence with only five prior reports, three originating from primaries in the sacrococcygeal region, one from a lumbar spine primary and the other from a primary arising from the spheno-occipital region. A literature review did not reveal any prior reports of mandibular metastasis at presentation from a clival chordoma. We possibly report the first case of such an unusual clinical scenario in a 7-year-old male child and further discuss the evaluation and management of these rare tumors.


Assuntos
Cordoma/patologia , Neoplasias de Cabeça e Pescoço/secundário , Neoplasias Mandibulares/secundário , Neoplasias da Base do Crânio/patologia , Biomarcadores Tumorais/metabolismo , Criança , Cordoma/cirurgia , Neoplasias de Cabeça e Pescoço/cirurgia , Humanos , Masculino , Neoplasias Mandibulares/cirurgia , Gradação de Tumores , Neoplasias da Base do Crânio/cirurgia
7.
Artigo em Inglês | MEDLINE | ID: mdl-32682593

RESUMO

OBJECTIVES: Oral and maxillofacial tumors involving the skull base (SB) are rare and complex, making treatment difficult and controversial. The purpose of the present study was to evaluate the treatment efficacy of craniofacial surgery (CFS). STUDY DESIGN: Patients who underwent CFS for these tumors between May 2000 and November 2017 were retrospectively analyzed. Clinicopathologic and treatment modality data were collected and follow-up was recorded. Kaplan-Meier and log-rank tests and Cox-regression model were used for survival analysis. RESULTS: In total, 126 patients were enrolled (70 males and 56 females; 97 malignant tumors). Squamous cell carcinoma accounted for the majority of tumors. The lip-submandibular-neck approach was most frequently applied. Through-and-through SB bone or partial dura resection was performed in 42 cases. A pathologic positive margin was found in 18 cases. Of the included patients, 80 underwent simultaneous craniofacial reconstruction. The postoperative complications rate was 11.1%. Estimated 1-year, 3-year, and 5-year overall survival rates were 78.8%, 68.2%, and 54.4% respectively; and the 1-year, 3-year, and 5-year recurrence-free survival rates were 77.4%, 66.8%, and 63.8%, respectively. Multivariate analysis indicated postoperative complications, radiotherapy, recurrence, and metastasis status had a negative impact on survival (P < .05). CONCLUSIONS: Although tumors involving the SB had various clinicopathologic characteristics, with interdisciplinary cooperation, CFS is an optimal option.


Assuntos
Carcinoma de Células Escamosas , Neoplasias da Base do Crânio , Feminino , Humanos , Masculino , Recidiva Local de Neoplasia , Estudos Retrospectivos , Base do Crânio , Neoplasias da Base do Crânio/cirurgia , Taxa de Sobrevida , Resultado do Tratamento
10.
Rhinology ; 58(4): 377-383, 2020 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-32352451

RESUMO

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


Assuntos
Cordoma , Neoplasias da Base do Crânio , Cordoma/cirurgia , Humanos , Recidiva Local de Neoplasia/cirurgia , Nariz , Neoplasias da Base do Crânio/cirurgia
11.
World Neurosurg ; 139: e761-e768, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32360921

RESUMO

BACKGROUND: Symptomatic trigeminal neuralgia caused by small (<3 cm) skull base meningiomas is treated by radiosurgery or surgical resection. Although radiosurgery is less invasive, surgical resection provides more rapid resolution of symptoms. We reviewed a short series of patients who underwent an anterior transpetrosal approach for surgical resection of meningiomas causing trigeminal neuralgia. METHODS: A retrospective review of 5 consecutive patients with meningiomas causing trigeminal neuralgia of the senior author was included. Preoperative parameters (size, proximity to critical neurovascular structures, presence of brainstem compression), intraoperative parameters (Simpson grade of resection, loss of brainstem evoked potentials, surgical approach), and outcomes (symptom resolution, extent of resection, follow-up) were recorded. RESULTS: Patient median age was 67 years (range, 60-73 years). All patients had symptoms concerning trigeminal neuralgia with 2 having associated areas of facial numbness. The anterior transpetrosal approach was used to achieve complete resection (Simpson grade I). Postresection, the trigeminal nerve and brainstem were clearly visible to evaluate neurovascular structures and ensure decompression. No postoperative complications were reported, and all patients experienced sustained symptomatic relief 1 month postsurgery. CONCLUSIONS: With the advent of radiosurgery for skull base meningiomas, surgical resection is not always considered; however, such meningiomas causing trigeminal neuralgia can be resected safely using the anterior transpetrosal approach allowing rapid resolution of symptoms. This review of operative nuances provides a guide for neurosurgeons to provide safe surgical resection.


Assuntos
Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Procedimentos Neurocirúrgicos/métodos , Neoplasias da Base do Crânio/cirurgia , Neuralgia do Trigêmeo/etiologia , Idoso , Feminino , Humanos , Masculino , Neoplasias Meníngeas/complicações , Meningioma/complicações , Pessoa de Meia-Idade , Estudos Retrospectivos , Neoplasias da Base do Crânio/complicações
12.
World Neurosurg ; 139: 535-547, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32371076

RESUMO

BACKGROUND: Pediatric meningiomas account for less than 2% of pediatric brain tumors. Pediatric clear cell meningiomas (CCMs) occurring in the posterior fossa are particularly rare. Therapeutic strategies differ among the previous pediatric CCM case reports. Therefore, to clarify the clinical features of pediatric CCMs, we report a rare case of dumbbell-type pediatric CCM and a corresponding literature review. CASE DESCRIPTION: A 7-year-old boy with complaints of headache, left facial palsy, dysarthria, and left-sided ataxic gait was emergently admitted to our hospital. His consciousness level was slight stupor, with Glasgow Coma Scale score 3-5-6, and he showed left ptosis, dysarthria, and ataxias of the left trunk and extremities. Magnetic resonance imaging (MRI) scan showed acute obstructive hydrocephalus because of the tumor's compression of the brainstem. The dumbbell-shaped tumor extended from the lateral wall of the cavernous sinus, through the left Meckel's cave, to the cerebellopontine angle. Physical examination and perioperative MRI scan showed no evidence regarding neurofibromatosis type I or II. The tumor was removed in a 2-staged operation. Postoperative proton therapy was done to treat some residual tumors. One year after postoperative proton therapy, there is no recurrence, and apart from left corneal and facial hypesthesia, he is healthy. CONCLUSIONS: We reported a rare case of pediatric skull base-type CCM with huge extension originating from the anteromedial wall of Meckel's cave firmly adhered to the cavernous sinus wall to the posterior fossa that was successfully treated with surgery and postoperative proton therapy. CCM has a high recurrence rate; therefore, careful prolonged follow-up is needed.


Assuntos
Neoplasias Meníngeas/diagnóstico por imagem , Neoplasias Meníngeas/cirurgia , Meningioma/diagnóstico por imagem , Meningioma/cirurgia , Neoplasias da Base do Crânio/diagnóstico por imagem , Neoplasias da Base do Crânio/cirurgia , Seio Cavernoso/diagnóstico por imagem , Seio Cavernoso/cirurgia , Criança , Progressão da Doença , Humanos , Masculino
13.
Neurochirurgie ; 66(3): 174-178, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32277999

RESUMO

BACKGROUND: Long-term use of high-dose progestin is known to promote the development of meningioma. Atypical meningioma in a patient under progestin has not previously been reported. CASE REPORT: A 53-year-old right-handed woman presented with focal onset seizures, without impaired consciousness. Medical history featured endometriosis, treated successively by cyproterone acetate 25mg/day for 2 months then 50mg/day for 101 months, and chlormadinone acetate 5mg/day for 68 months then 10mg/day for 83 months. Brain MRI revealed multiple extra-axial lesions suggestive of left central meningioma associated with anterior skull base meningiomatosis. Surgical resection of the left central meningioma was achieved and progestin was withdrawn. Neuropathology diagnosed grade II atypical meningioma. Close clinical and imaging monitoring was implemented without adjuvant oncological treatment. At 25 months, imaging follow-up showed no recurrence of the left central meningioma and a significant regression of all other lesions, except for the right frontal lesion. CONCLUSIONS: Neurosurgeons should be aware of the possible aggressiveness of meningioma in patients under progestin, and particularly those treated by different types of progestin over a long period of time without interruption. This may require systematic close monitoring, to adapt neurosurgical management.


Assuntos
Meningioma/metabolismo , Progestinas/metabolismo , Neoplasias da Base do Crânio/metabolismo , Progressão da Doença , Feminino , Humanos , Imagem por Ressonância Magnética , Meningioma/diagnóstico por imagem , Meningioma/cirurgia , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Progesterona/antagonistas & inibidores , Neoplasias da Base do Crânio/diagnóstico por imagem , Neoplasias da Base do Crânio/cirurgia , Resultado do Tratamento
15.
World Neurosurg ; 140: 378-388.e2, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32302729

RESUMO

BACKGROUND: Cranial base chordomas are complex lesions centered on the clivus that surgically can be approached from either a midline or a lateral corridor. OBJECTIVE: To compare the surgical outcomes from midline versus lateral approaches by conducting a meta-analysis of the literature. METHODS: Studies were identified between 2000 and 2018. The primary outcome was gross total resection (GTR) rate. The secondary outcomes were recurrence rate and rates of cerebrospinal fluid (CSF) leak and new cranial nerve palsy. Odds ratios were calculated with a random-effect model using studies describing both approaches. An indirect (proportion) meta-analysis was performed pooling studies describing either of the approaches. Individual patient data were analyzed for differences in GTR or recurrence rate with different tumor extensions. RESULTS: Thirty-three studies were found suitable for indirect meta-analysis and 10 studies for direct meta-analysis. The overall odds of GTR with a midline approach compared with a lateral approach was 0.83 (95% confidence interval [CI], -0.43 to 1.62). The odds ratios for recurrence, CSF leak, and new cranial nerve palsy were 0.82 (95% CI, 0.26-2.56), 1.49 (95% CI, 0.14-15.5), and 0.14 (95% CI, 0.04-0.56), respectively. With individual patient data analysis, no statistically significant difference was observed in GTR or recurrence rates between the 2 approaches with different tumor extensions. CONCLUSIONS: The meta-analysis did not show any significant difference in GTR or recurrence rates between the midline versus lateral approaches. Tumor extension to different compartments did not affect the GTR or recurrence rates with either approach. In terms of complications, CSF leak rate was higher in midline approaches and cranial nerve palsy was higher in lateral approaches.


Assuntos
Cordoma/cirurgia , Procedimentos Neurocirúrgicos/métodos , Neoplasias da Base do Crânio/cirurgia , Fossa Craniana Posterior/cirurgia , Humanos , Cirurgia Endoscópica por Orifício Natural , Resultado do Tratamento
16.
World Neurosurg ; 139: 460-470, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32330621

RESUMO

OBJECTIVE: The influence of graft type (nonautologous vs. autologous) on surgical outcomes in endoscopic anterior skull base (EASB) reconstruction is not well understood. This review systematically evaluated rates of postoperative complications of EASB repairs that utilized autologous or nonautologous grafts. METHODS: Original studies reporting EASB reconstruction outcomes were extracted from PubMed, Ovid, and the Cochrane Library from database inception to 2019. Risk ratios, risk differences, χ2 tests, and multivariate logistic regression were used to evaluate outcome measures: postoperative cerebrospinal fluid (CSF) leaks, meningitis, and other major complications (OMCs). RESULTS: A total of 2275 patients from 29 studies were analyzed. Rates of postoperative CSF leaks, meningitis, and OMCs were 4.0%, 1.6%, and 2.3%, respectively, using autologous grafts, and 5.0%, 0.3%, and 1.0%, respectively, using nonautologous grafts. Multivariate analysis of 118 patients demonstrated no significant differences in age, CSF flow rate, single or multilayer reconstruction, and presence of intraoperative CSF leak or lumbar drain. Meta-analyses of 6 studies yielded a risk ratio of 0.64 (95% confidence interval [CI], 0.19-2.14; P = 0.47) for postoperative CSF leakage, and risk differences of -0.01 (95% CI, -0.06 to 0.05; P = 0.80) and -0.02 (95% CI, -0.09 to 0.05; P = 0.51) for postoperative meningitis and OMCs, respectively. There were no significant differences in postoperative CSF leakage (P = 0.95) and OMCs (P = 0.41) between graft types among cases with intraoperative CSF leaks. However, meningitis rates were lower (P = 0.04) in the nonautologous group. CONCLUSIONS: EASB reconstructions utilizing autologous and nonautologous grafts are associated with similar rates of postoperative CSF leakage and OMCs. In cases with intraoperative CSF leakage, nonautologous grafts were associated with reduced postoperative meningitis.


Assuntos
Neuroendoscopia/métodos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Neoplasias da Base do Crânio/cirurgia , Base do Crânio/cirurgia , Transplantes/transplante , Vazamento de Líquido Cefalorraquidiano/epidemiologia , Vazamento de Líquido Cefalorraquidiano/prevenção & controle , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Neoplasias da Base do Crânio/diagnóstico por imagem , Neoplasias da Base do Crânio/epidemiologia , Retalhos Cirúrgicos/transplante
17.
World Neurosurg ; 138: e940-e954, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32298827

RESUMO

BACKGROUND AND OBJECTIVE: Endoscopic endonasal surgery (EES) for the management of sellar, suprasellar, and anterior skull base lesions is gaining popularity. Our aim was to analyze and present the clinical outcomes of EES for the management of these lesions in a community hospital setting. METHODS: We retrospectively reviewed the charts of 56 patients with sellar, suprasellar, and anterior skull base lesions who underwent EES between 2010 and 2018. RESULTS: There was male predominance (53.6%) with a mean age of 54.9 ± 13.7 years. Lesions were 45 pituitary adenomas, 5 meningiomas, 3 metastatic, 1 craniopharyngioma, 1 Rathke cyst, and 1 mucocele. Gross total excision was achieved in 57.1%, subtotal excision occurred in 37.5%, and decompression and biopsy were achieved in 5.4% patients. Postoperative vision normalized or improved in 27 patients (86.1%) and was stable in 4 patients (13.9%). Recovery of a preexisting hormonal deficit occurred in 13 (23.2%) patients, and a new hormonal deficit occurred in 9 patients (16.1%). The mean hospital stay was 6.1 ± 4.9 days. Postoperative complications included cerebrospinal fluid leak in 8 patients (14.3%). Four patients (7.1%) had meningitis. Diabetes insipidus was present in 19 patients (33.9%), and postoperative intracranial hematoma requiring evacuation was necessary in 2 patients (3.6%). The mean follow-up duration was 47.5 ± 25.8 months. Lesion progression or recurrence requiring redo surgery occurred in 5 patients (8.9%). Regarding the learning curve, the postoperative cerebrospinal fluid leak, meningitis, new hormonal deficits, and diabetes insipidus decreased in the second half of the patients. CONCLUSIONS: EES provides an effective and safe surgical option with low morbidity and mortality for the treatment of sellar, suprasellar, and anterior skull base lesions in a community hospital setting.


Assuntos
Endoscopia , Procedimentos Neurocirúrgicos , Sela Túrcica/cirurgia , Neoplasias da Base do Crânio/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Fossa Craniana Anterior/cirurgia , Endoscopia/educação , Endoscopia/métodos , Feminino , Hospitais Comunitários , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/educação , Estudos Retrospectivos , Resultado do Tratamento
18.
World Neurosurg ; 139: 343, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32272265

RESUMO

Fluorescence-guided resection of brain tumors using 5-aminolevulinic acid (5-ALA) has been established for high-grade gliomas. Recently, its application for the resection of low grade tumors and benign lesions including meningioma has been suggested in the literature.1 Achieving a Simpson grade I resection in meningioma surgery is associated with a lower rate of recurrence.2,3 Although meningiomas are mostly benign and well-circumscribed lesions, they can be locally aggressive, invading brain parenchyma and other critical structures. In these cases, 5-ALA-guided resection may help maximize the extent of tumor resection and limit disruption of normal structures. In this video, we present 3 cases demonstrating the use of 5-ALA-induced fluorescence to alleviate 3 specific challenges in meningioma resection: 1) to aid visualization with a minimally invasive approach, 2) to distinguish recurrent tumor from scar tissue from prior treatments, and 3) to ensure that no viable tumor cells remain on the surface of a critical artery. The first patient is a 60-year-old woman who was found to have an incidental left sphenoid wing meningioma on magnetic resonance imaging. We elected for an extended lateral orbital craniotomy through a transpalpebral approach. The second patient is a 72-year-old man with recurrent left occipital parietal meningioma who underwent a parietal craniotomy. The third case was a 62-year-old woman with a foramen magnum meningioma encircling the left vertebral artery. These cases demonstrate the utility of 5-ALA in a variety of challenges associated with resection of meningiomas (Video 1).


Assuntos
Ácido Aminolevulínico , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Procedimentos Neurocirúrgicos/métodos , Imagem Óptica/métodos , Idoso , Feminino , Humanos , Masculino , Microcirurgia , Pessoa de Meia-Idade , Neoplasias da Base do Crânio/cirurgia
19.
World Neurosurg ; 139: e61-e69, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32289512

RESUMO

OBJECTIVE: The trend toward minimally invasive surgery has led to a reduction in the size of craniotomies, use of endoscopic assistance to minimize the surgeon's footprint and aid with visualization, and use of alternatives to microsurgery, such as endovascular embolization for aneurysms and radiosurgery for skull base pathologies. A movement away from the use of fixed retractors has also been heralded as an advance in skull base surgery, but the data on the utility of a retractorless approach is small and limited to highly experienced surgeons, often with several decades of experience. This has led some to suggest that retractorless surgery may be unsafe, especially in the hands of young surgeons, in an era where the majority of complex vascular pathology has transitioned to endovascular treatment, and many skull base lesions are treated with chemoradiotherapy adjuncts. METHODS: This 19-month study prospectively analyzed the use of retractorless surgery in a consecutive series of 139 lesions in 119 patients with complex intracranial vascular and skull base pathology undergoing craniotomy by a single surgeon. RESULTS: The microsurgical approaches included orbitozygomatic craniotomy (40 [28.7%]), supratentorial nonskull base approaches (25 [17.9%]), pterional/minipterional (16 [11.5%]), interhemispheric (12 [8.6%]), suboccipital (11 [7.9%]), and an array of other approaches, such as presigmoid, supracerebellar-infratentorial, far lateral, and retrosigmoid approaches. The most common pathology included aneurysms (47 [33.8%]), skull base tumors (32 [23%]), deep-seated lesions (24 [17.3%]), cavernous malformations (10 [7.2%]), arteriovenous malformations (10 [7.2%]), and arteriovenous fistulae (5 [3.6%]). Of the 139 lesions, 8 (5.75%) cases required the use of a fixed retractor. In total, 94.25% of the cases were successfully treated without a self-retaining retractor system. CONCLUSIONS: Retractorless surgery can be performed safely, even by young surgeons, in an era where the majority of complex neurovascular and skull base pathology is treated by endovascular and radiosurgical means. Retractorless surgery can be used in the majority of cases, especially if careful attention is paid to patient positioning, microsurgical dissection of arachnoid planes is carried out to access deep corridors, gravity retraction is used in lieu of fixed retractors, and judicious dynamic retraction with the shafts of instruments replaces the blades of a fixed retractor system.


Assuntos
Aneurisma Intracraniano/cirurgia , Microcirurgia/instrumentação , Procedimentos Neurocirúrgicos/instrumentação , Neoplasias da Base do Crânio/cirurgia , Instrumentos Cirúrgicos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Fístula Arteriovenosa/cirurgia , Criança , Craniotomia , Feminino , Hemangioma Cavernoso do Sistema Nervoso Central/cirurgia , Humanos , Malformações Arteriovenosas Intracranianas/cirurgia , Masculino , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Microcirurgia/métodos , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/métodos , Estudos Prospectivos , Adulto Jovem
20.
World Neurosurg ; 138: 83, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32145415

RESUMO

Skull base tumors arising from the middle cranial fossa and invading of the infratemporal fossa (ITF) and middle cranial fossa are challenging for neurosurgeons, because of complex anatomy and critical neurovascular structure involvement. The first pioneering ITF approaches resulted in invasive procedures and carried a high rate of surgical morbidity. However, the acquisition of deep anatomical knowledge, and the development operative skills and reconstruction techniques allowed surgeons to achieve total or near total resection of many ITF lesions with a low morbidity rate. In Video 1 we illustrate our technique for the anterior ITF approach for the surgical treatment of a middle cranial fossa meningioma invading the ITF. This surgical video describes the anterior ITF approach in 2 steps. First, a standard extradural middle fossa approach subtemporal approach is performed on a cadaveric specimen, illustrating the anterior extension to the cavernous sinus. Second, the anterior ITF approach is performed for the surgical treatment of a temporal lobe meningioma with extension to the anterior ITF. This technique provides a minimally invasive approach for treating middle fossa lesions with anterior ITF extension.


Assuntos
Fossa Craniana Média/cirurgia , Fossa Infratemporal/cirurgia , Meningioma/cirurgia , Procedimentos Neurocirúrgicos/métodos , Neoplasias da Base do Crânio/cirurgia , Cadáver , Craniotomia , Humanos , Pessoa de Meia-Idade
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