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Open AccessEditorial

Editorial for Brain Sciences Special Issue: “Advances in Skull Base Tumor Surgery: The Practical Pearls”

by Miguel Angel Lopez-Gonzalez

Brain Sci. 2024, 14(4), 352; https://doi.org/10.3390/brainsci14040352 - 1 Apr 2024

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Abstract

The field of skull base surgery is unique; it involves the adequate and coordinated multidisciplinary interaction of multiple specialties, such as otorhinolaryngology, maxillofacial surgery, ophthalmology, neuro-anesthesiology, oncology, radiation oncology, neurophysiology, and neurosurgery [...] Full article

(This article belongs to the Special Issue Advances in Skull Base Tumor Surgery: The Practical Pearls)

Research

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19 pages, 8008 KiB

Open AccessArticle

Gruppo Otologico’s Experience in Managing the So-Called Inoperable Tympanojugular Paraganglioma

by Mario Sanna, Mohammed Al-Khateeb, Melcol Hailu Yilala, Mohanad Almashhadani and Giuseppe Fancello

Brain Sci. 2024, 14(8), 745; https://doi.org/10.3390/brainsci14080745 - 25 Jul 2024

Cited by 1 | Viewed by 1116

Abstract

Objective: to identify advanced or “so-called inoperable” cases of tympanojugular paragangliomas (PGLs) and analyze how each case is surgically managed and followed afterward. Study Design: a retrospective case series study. Methods: Out of 262 type C and D TJPs and more [...] Read more.

Objective: to identify advanced or “so-called inoperable” cases of tympanojugular paragangliomas (PGLs) and analyze how each case is surgically managed and followed afterward. Study Design: a retrospective case series study. Methods: Out of 262 type C and D TJPs and more than 10 cases of advanced or so-called inoperable cases, files of 6 patients with a diagnosis of advanced tympanojugular PGLs who were referred to an otology and skull-base center between 1996 and 2021 were reviewed to analyze management and surgical outcomes. The criteria for choosing these cases involve having one or more of the following features: (1) a large-sized tumor; (2) a single ipsilateral internal carotid artery (ICA); (3) involvement of the vertebral artery; (4) a considerable involvement of the ICA; (5) an extension to the clivus, foramen magnum, and cavernous sinus; (6) large intradural involvement (IDE); and (7) bilateral or multiple PGLs. Results: The age range at presentation was 25–43 years old, with a mean of 40.5 years: two females and four males. The presenting symptoms were glossal atrophy, hearing loss, pulsatile tinnitus, dysphonia, shoulder weakness, and diplopia. The modified Infratemporal Fossa Approach (ITFA) with a transcondylar–transtubercular extension is the principal approach in most cases, with additional approaches being used accordingly. Conclusions: The contemporary introduction of carotid artery stenting with the direct and indirect embolization of PGLs has made it possible to operate on many cases, which was otherwise considered impossible to treat surgically. Generally, the key is to stage the removal of the tumor in multiple stages during the management of complex PGLs to decrease surgical morbidities. A crucial aspect is to centralize the treatment of PGLs in referral centers with experienced surgeons who are trained to plan the stages and manage possible surgical complications. Full article

(This article belongs to the Special Issue Advances in Skull Base Tumor Surgery: The Practical Pearls)

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(Case 1) (a) Axial-enhanced T1W MRI, with large intradural tumor extension. (b) Axial-enhanced T1W MRI, with extensive involvement of posterior fossa dura with intradural and IAC involvement. (c) Plain lateral view skull X-ray. Red arrows indicate balloons during permanent occlusion of the IAC. (d) Intra-carotid stent was seen after opening the wall of the carotid artery. (e) Axial-enhanced T1W MRI revealing dural infiltration and the involvement of IAC. Full article ">Figure 2
(Case 2) (a,b) Enhanced-axial T1W MRI showing C3Di1 + stage I VP. (c,d) Postoperative axial and coronal MRI showing no residual tumor. Full article ">Figure 3
(Case 3) (a) CT scan, coronal view, of tumor extending into the craniocervical junction. (b) Axial-enhanced T1W MRI showing the tumor extension into the vertical segment of ICA. (c) Axial view, CT, after 1st stage showing residual tumor around horizontal ICA and PA. (d) X-ray screen shows ICA stenting at the level of foramen lacerum. (e) Stented ICA after removal of tumor-invaded adventitia. (f) Axial-enhanced T1W MRI showing residual tumor in the cavernous sinus. (g) Enhanced T1W MRI after 4th stage [<a href="#B1-brainsci-14-00745" class="html-bibr">1</a>]. Full article ">Figure 3 Cont.
(Case 3) (a) CT scan, coronal view, of tumor extending into the craniocervical junction. (b) Axial-enhanced T1W MRI showing the tumor extension into the vertical segment of ICA. (c) Axial view, CT, after 1st stage showing residual tumor around horizontal ICA and PA. (d) X-ray screen shows ICA stenting at the level of foramen lacerum. (e) Stented ICA after removal of tumor-invaded adventitia. (f) Axial-enhanced T1W MRI showing residual tumor in the cavernous sinus. (g) Enhanced T1W MRI after 4th stage [<a href="#B1-brainsci-14-00745" class="html-bibr">1</a>]. Full article ">Figure 4
(Case 5) (a,b) Right tympanojugular paraganglioma (C3Di2Vi) involving the clivus, the vertebral artery, the foramen magnum, and the occipital condyle. (c) Axial-enhanced T1-weighted magnetic resonance imaging (MRI) shows a large mass extending to the intradural space up to the foramen magnum. (d) Axial-enhanced T1 MRI after first-stage tumor removal. (e) Enhanced T1 MRI after second-stage surgery. (d,f) Axial-enhanced T1 MRI after third-stage tumor removal, which shows total tumor removal with obliteration of the surgical cavity with abdominal fat. (g) A sagittal CT scan after total tumor removal during the third stage shows cervical–occipital fixation. Full article ">Figure 4 Cont.
(Case 5) (a,b) Right tympanojugular paraganglioma (C3Di2Vi) involving the clivus, the vertebral artery, the foramen magnum, and the occipital condyle. (c) Axial-enhanced T1-weighted magnetic resonance imaging (MRI) shows a large mass extending to the intradural space up to the foramen magnum. (d) Axial-enhanced T1 MRI after first-stage tumor removal. (e) Enhanced T1 MRI after second-stage surgery. (d,f) Axial-enhanced T1 MRI after third-stage tumor removal, which shows total tumor removal with obliteration of the surgical cavity with abdominal fat. (g) A sagittal CT scan after total tumor removal during the third stage shows cervical–occipital fixation. Full article ">Figure 5
(Case 6) (a,b) Right-sided tympanojugular PGL (C4Di2Vi). (c) Coronal Gd-enhanced T1-weighted magnetic resonance imaging (MRI) shows a large residual tumor extending to the intradural space involving the vertebral artery. (d) Axial Gd-enhanced T1-weighted MRI shows a large residual tumor extending to the intradural space, involving transverse sinus ipsilaterally up to the torcula. (e) Coronal Gd-enhanced T1-weighted MRI after first-stage tumor removal. Note the residual tumor: T1 is in the cerebellopontine angle, and T2 is in the foramen magnum. (f) Coronal Gd-enhanced T1-weighted MRI after second-stage tumor removal, which shows a small residual tumor at the foramen magnum. (g,h) Axial and coronal Gd-enhanced T1-weighted MRI after third-stage tumor removal, which revealed total tumor removal at the level of the foramen magnum. (i,j) Axial CT scan after the third stage shows a coil at the internal carotid and vertebral arteries that are used for artery occlusion. Full article ">Figure 5 Cont.
(Case 6) (a,b) Right-sided tympanojugular PGL (C4Di2Vi). (c) Coronal Gd-enhanced T1-weighted magnetic resonance imaging (MRI) shows a large residual tumor extending to the intradural space involving the vertebral artery. (d) Axial Gd-enhanced T1-weighted MRI shows a large residual tumor extending to the intradural space, involving transverse sinus ipsilaterally up to the torcula. (e) Coronal Gd-enhanced T1-weighted MRI after first-stage tumor removal. Note the residual tumor: T1 is in the cerebellopontine angle, and T2 is in the foramen magnum. (f) Coronal Gd-enhanced T1-weighted MRI after second-stage tumor removal, which shows a small residual tumor at the foramen magnum. (g,h) Axial and coronal Gd-enhanced T1-weighted MRI after third-stage tumor removal, which revealed total tumor removal at the level of the foramen magnum. (i,j) Axial CT scan after the third stage shows a coil at the internal carotid and vertebral arteries that are used for artery occlusion. Full article ">

11 pages, 3048 KiB

Open AccessArticle

Multi-Disciplinary Approach to Skull Base Paragangliomas

by Steven D. Curry, Armine Kocharyan and Gregory P. Lekovic

Brain Sci. 2023, 13(11), 1533; https://doi.org/10.3390/brainsci13111533 - 31 Oct 2023

Cited by 3 | Viewed by 1620

Abstract

The treatment of skull base paragangliomas has moved towards the use of cranial nerve preservation strategies, using radiation therapy and subtotal resection in instances when aiming for gross total resection would be expected to cause increased morbidity compared to the natural history of [...] Read more.

The treatment of skull base paragangliomas has moved towards the use of cranial nerve preservation strategies, using radiation therapy and subtotal resection in instances when aiming for gross total resection would be expected to cause increased morbidity compared to the natural history of the tumor itself. The goal of this study was to analyze the role of surgery in patients with skull base paragangliomas treated with CyberKnife stereotactic radiosurgery (SRS) for definitive tumor control. A retrospective review identified 22 patients (median age 65.5 years, 50% female) treated with SRS from 2010–2022. Fourteen patients (63.6%) underwent microsurgical resection. Gross total resection was performed in four patients for tympanic paraganglioma (n = 2), contralateral paraganglioma (n = 1), and intracranial tumor with multiple cranial neuropathies (n = 1). Partial/subtotal resection was performed for the treatment of pulsatile tinnitus and conductive hearing loss (n = 6), chronic otitis and otorrhea (n = 2), intracranial extension (n = 1), or episodic vertigo due to perilymphatic fistula (n = 1). Eighteen patients had clinical and imaging follow-up for a mean (SD) of 4.5 (3.4) years after SRS, with all patients having clinical and radiological tumor control and no mortalities. Surgery remains an important component in the multidisciplinary treatment of skull base paraganglioma when considering other outcomes besides local tumor control. Full article

(This article belongs to the Special Issue Advances in Skull Base Tumor Surgery: The Practical Pearls)

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T1-weighted contrast-enhanced MRI of a patient with a Fisch class D jugular paraganglioma who underwent an infratemporal fossa approach for gross total resection of the tumor. The axial pre-surgery image in (A) shows brainstem compression from a contrast-enhancing tumor. Part (B) shows an axial image slightly more cranial compared to the image in (A) showing a fat graft that was used to reconstruct the surgical defect. The coronal pre-surgery image in (C) shows contrast-enhancing tumor extending from the jugular bulb to the cerebellopontine angle. The post-surgery image in (D) shows the removal of intracranial tumor, with a fat graft visible. Arrows in (A,C) indicate tumor. Arrowheads in (B,D) indicate fat graft. Full article ">Figure 2
MRI and CT imaging of a patient with a Fisch class C jugular paraganglioma who underwent a modified infratemporal fossa approach for subtotal tumor resection for relief of pulsatile tinnitus and conductive hearing loss. Axial T1-weighted contrast-enhanced MRI presurgical (A) and postsurgical (B) imaging shows persistent tumor in the area of the jugular bulb. Axial CT bone window (C) postsurgical imaging shows no persistent tumor adjacent to the cochlea. Coronal T1-weighted contrast-enhanced MRI presurgical (D) and postsurgical (E) images show an interval decreased in tumor. Coronal CT bone window (F) postsurgical imaging shows no persistent tumor in the mesotympanum or hypotympanum. Arrows in (A,B,D,E) indicate tumor. Arrowheads in (C,F) show the absence of tumor in the middle ear. Full article ">

8 pages, 817 KiB

Open AccessArticle

Comparison of Surgeons’ Assessment of the Extent of Vestibular Schwannoma Resection with Immediate Post Operative and Follow-Up Volumetric MRI Analysis

by Hossein Mahboubi, William H. Slattery III, Mia E. Miller and Gregory P. Lekovic

Brain Sci. 2023, 13(10), 1490; https://doi.org/10.3390/brainsci13101490 - 22 Oct 2023

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Abstract

(1) Background: Incomplete excision of vestibular schwannomas (VSs) is sometimes preferable for facial nerve preservation. On the other hand, subtotal resection may be associated with higher tumor recurrence. We evaluated the correlation between intra-operative assessment of residual tumor and early and follow-up imaging. [...] Read more.

(1) Background: Incomplete excision of vestibular schwannomas (VSs) is sometimes preferable for facial nerve preservation. On the other hand, subtotal resection may be associated with higher tumor recurrence. We evaluated the correlation between intra-operative assessment of residual tumor and early and follow-up imaging. (2) Methods: The charts of all patients undergoing primary surgery for sporadic vestibular schwannoma during the study period were retrospectively reviewed. Data regarding surgeons’ assessments of the extent of resection, and the residual size of the tumor on post-operative day (POD) one and follow-up MRI were extracted. (3) Results: Of 109 vestibular schwannomas meeting inclusion criteria, gross-total resection (GTR) was achieved in eighty-four, near-total (NTR) and sub-total resection (STR) in twenty-two and three patients, respectively. On follow up imaging, volumetric analysis revealed that of twenty-two NTRs, eight were radiographic GTR and nine were radiographic STR (mean volume ratio 11.9%), while five remained NTR (mean volume ratio 1.8%). Of the three STRs, two were radiographic GTR while one remained STR. Therefore, of eighteen patients with available later follow up MRIs, radiographic classification of the degree of resection changed in six. (4) Conclusions: An early MRI (POD#1) establishes a baseline for the residual tumor that may be more accurate than the surgeon’s intraoperative assessment and may provide a beneficial point of comparison for long-term surveillance. Full article

(This article belongs to the Special Issue Advances in Skull Base Tumor Surgery: The Practical Pearls)

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9 pages, 5223 KiB

Open AccessArticle

A New Finding on Magnetic Resonance Imaging for Diagnosis of Hemifacial Spasm with High Accuracy and Interobserver Correlation

by Guilherme Finger, Kyle C. Wu, Joshua Vignolles-Jeong, Saniya S. Godil, Ben G. McGahan, Daniel Kreatsoulas, Mohammad T. Shujaat, Luciano M. Prevedello and Daniel M. Prevedello

Brain Sci. 2023, 13(10), 1434; https://doi.org/10.3390/brainsci13101434 - 9 Oct 2023

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Abstract

Among patients with clinical hemifacial spasm (HFS), imaging exams aim to identify the neurovascular conflict (NVC) location. It has been proven that the identification in the preoperative exam increases the rate of surgical success. Despite the description of specific magnetic resonance image (MRI) [...] Read more.

Among patients with clinical hemifacial spasm (HFS), imaging exams aim to identify the neurovascular conflict (NVC) location. It has been proven that the identification in the preoperative exam increases the rate of surgical success. Despite the description of specific magnetic resonance image (MRI) acquisitions, the site of neurovascular compression is not always visualized. The authors describe a new MRI finding that helps in the diagnosis of HFS, and evaluate the sensitivity, specificity, and interobserver correlation of the described sign. A cross-sectional study including cases of hemifacial spasm treated surgically from 1 August 2011 to 31 July 2021 was performed. The MRIs of the cases were independently evaluated by two experienced neuroradiologists, who were blinded regarding the side of the symptom. The neuroradiologists were assigned to evaluate the MRIs in two separate moments. Primarily, they evaluated whether there was a neurovascular conflict based on the standard technique. Following this initial analysis, the neuroradiologists received a file with the description of the novel sign, named Prevedello Sign (PS). In a second moment, the same neuroradiologists were asked to identify the presence of the PS and, if it was present, to report on which side. A total of 35 patients were included, mostly females (65.7%) with a mean age of 59.02 (+0.48). Since the 35 cases were independently evaluated by two neuroradiologists, a total of 70 reports were included in the analysis. The PS was present in 66 patients (sensitivity of 94.2%, specificity of 91.4% and positive predictive value of 90.9%). When both analyses were performed in parallel (standard plus PS), the sensitivity increased to 99.2%. Based on the findings of this study, the authors conclude that PS is helpful in determining the neurovascular conflict location in patients with HFS. Its presence, combined with the standard evaluation, increases the sensitivity of the MRI to over 99%, without increasing risks of harm to patients or resulting in additional costs. Full article

(This article belongs to the Special Issue Advances in Skull Base Tumor Surgery: The Practical Pearls)

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16 pages, 7122 KiB

Open AccessArticle

A New Perspective on the Cavernous Sinus as Seen through Multiple Surgical Corridors: Anatomical Study Comparing the Transorbital, Endonasal, and Transcranial Routes and the Relative Coterminous Spatial Regions

by Sergio Corvino, Pedro L. Villanueva-Solórzano, Martina Offi, Daniele Armocida, Motonobu Nonaka, Giorgio Iaconetta, Felice Esposito, Luigi Maria Cavallo and Matteo de Notaris

Brain Sci. 2023, 13(8), 1215; https://doi.org/10.3390/brainsci13081215 - 17 Aug 2023

Cited by 14 | Viewed by 1946

Abstract

Background: The cavernous sinus (CS) is a highly vulnerable anatomical space, mainly due to the neurovascular structures that it contains; therefore, a detailed knowledge of its anatomy is mandatory for surgical unlocking. In this study, we compared the anatomy of this region [...] Read more.

Background: The cavernous sinus (CS) is a highly vulnerable anatomical space, mainly due to the neurovascular structures that it contains; therefore, a detailed knowledge of its anatomy is mandatory for surgical unlocking. In this study, we compared the anatomy of this region from different endoscopic and microsurgical operative corridors, further focusing on the corresponding anatomic landmarks encountered along these routes. Furthermore, we tried to define the safe entry zones to this venous space from these three different operative corridors, and to provide indications regarding the optimal approach according to the lesion’s location. Methods: Five embalmed and injected adult cadaveric specimens (10 sides) separately underwent dissection and exposure of the CS via superior eyelid endoscopic transorbital (SETOA), extended endoscopic endonasal transsphenoidal-transethmoidal (EEEA), and microsurgical transcranial fronto-temporo-orbito-zygomatic (FTOZ) approaches. The anatomical landmarks and the content of this venous space were described and compared from these surgical perspectives. Results: The oculomotor triangle can be clearly exposed only by the FTOZ approach. Unlike EEEA, for the exposure of the clinoid triangle content, the anterior clinoid process removal is required for FTOZ and SETOA. The supra- and infratrochlear as well as the anteromedial and anterolateral triangles can be exposed by all three corridors. The most recently introduced SETOA allowed for the exposure of the entire lateral wall of the CS without entering its neurovascular structures and part of the posterior wall; furthermore, thanks to its anteroposterior trajectory, it allowed for the disclosure of the posterior ascending segment of the cavernous ICA with the related sympathetic plexus through the Mullan’s triangle, in a minimally invasive fashion. Through the anterolateral triangle, the transorbital corridor allowed us to expose the lateral 180 degrees of the Vidian nerve and artery in the homonymous canal, the anterolateral aspect of the lacerum segment of the ICA at the transition zone from the petrous horizontal to the ascending posterior cavernous segment, surrounded by the carotid sympathetic plexus, and the medial Meckel’s cave. Conclusions: Different regions of the cavernous sinus are better exposed by different surgical corridors. The relationship of the tumor with cranial nerves in the lateral wall guides the selection of the approach to cavernous sinus lesions. The transorbital endoscopic approach can be considered to be a safe and minimally invasive complementary surgical corridor to the well-established transcranial and endoscopic endonasal routes for the exposure of selected lesions of the cavernous sinus. Nevertheless, peer knowledge of the anatomy and a surgical learning curve are required. Full article

(This article belongs to the Special Issue Advances in Skull Base Tumor Surgery: The Practical Pearls)

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18 pages, 2520 KiB

Open AccessArticle

Endoscopic Endonasal Transplanum–Transtuberculum Approach for Pituitary Adenomas/PitNET: 25 Years of Experience

by Alessandro Carretta, Matteo Zoli, Federica Guaraldi, Giacomo Sollini, Arianna Rustici, Sofia Asioli, Marco Faustini-Fustini, Ernesto Pasquini and Diego Mazzatenta

Brain Sci. 2023, 13(7), 1121; https://doi.org/10.3390/brainsci13071121 - 24 Jul 2023

Cited by 5 | Viewed by 1601

Abstract

The role of the endoscopic transplanum–transtuberculum approach (ETTA) in the treatment of pituitary adenomas/PitNETs (PAs) is sparsely analyzed in the literature, and its use is still debated in the current practice. The aim of this study was to report our experience with this [...] Read more.

The role of the endoscopic transplanum–transtuberculum approach (ETTA) in the treatment of pituitary adenomas/PitNETs (PAs) is sparsely analyzed in the literature, and its use is still debated in the current practice. The aim of this study was to report our experience with this approach. Our institutional registry was retrospectively reviewed, and patients who underwent ETTA for a PA from 1998 to 2022 were included. Fifty-seven cases were enrolled over a time span of 25 years, corresponding to 2.4% of our entire PA caseload. Radical resection was achieved in 57.9% of cases, with re-do surgery (p = 0.033) and vessel encasement/engulfment (p < 0.001) as predictors of partial resection. CSF leak incidence stood at 8.8%, with higher BMI (p = 0.038) as its only significant predictor. Partial or full improvement of the visual field deficits was achieved in 73.5% of cases. No surgical mortality was observed. According to our results, ETTA for the treatment of PAs is characterized by a satisfactory surgical outcome but with greater morbidity than the conventional endoscopic approach. Therefore, it should be reserved for the few selected cases otherwise unsuitable for the endoscopic trans-sphenoidal route, representing a valid alternative and an effective complementary route for the transcranial approach for these challenging PAs. Full article

(This article belongs to the Special Issue Advances in Skull Base Tumor Surgery: The Practical Pearls)

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12 pages, 1022 KiB

Open AccessArticle

Postoperative Cerebral Venous Sinus Thrombosis Following a Retrosigmoid Craniotomy—A Clinical and Radiological Analysis

by Lukasz Przepiorka, Katarzyna Wójtowicz, Katarzyna Camlet, Jan Jankowski, Sławomir Kujawski, Laretta Grabowska-Derlatka, Andrzej Marchel and Przemysław Kunert

Brain Sci. 2023, 13(7), 1039; https://doi.org/10.3390/brainsci13071039 - 7 Jul 2023

Cited by 1 | Viewed by 1582

Abstract

Postoperative cerebral venous sinus thrombosis (CVST) is a rare complication of the retrosigmoid approach. To address the lack of literature, we performed a retrospective analysis. The thromboses were divided into those demonstrating radiological (rCVST) and clinical (cCVST) features, the latter diagnosed during hospitalization. [...] Read more.

Postoperative cerebral venous sinus thrombosis (CVST) is a rare complication of the retrosigmoid approach. To address the lack of literature, we performed a retrospective analysis. The thromboses were divided into those demonstrating radiological (rCVST) and clinical (cCVST) features, the latter diagnosed during hospitalization. We identified the former by a lack of contrast in the sigmoid (SS) or transverse sinuses (TS), and evaluated the closest distance from the craniotomy to quantify sinus exposure. We included 130 patients (males: 52, females: 78) with a median age of 46.0. They had rCVST in 46.9% of cases, most often in the TS (65.6%), and cCVST in 3.1% of cases. Distances to the sinuses were not different regarding the presence of cCVST (p = 0.32 and p = 0.72). The distance to the SS was not different regarding rCVST (p = 0.13). However, lower exposure of the TS correlated with a lower incidence of rCVST (p = 0.009). When surgery was performed on the side of the dominant sinuses, rCVSTs were more frequent (p = 0.042). None of the other examined factors were related to rCVST or cCVST. Surgery on the side of the dominant sinus, and the exposing of them, seems to be related with rCVST. Further prospective studies are needed to identify the risk factors and determine the best management. Full article

(This article belongs to the Special Issue Advances in Skull Base Tumor Surgery: The Practical Pearls)

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9 pages, 7750 KiB

Open AccessCommunication

The Extended-Sphenoid Ridge Approach: A New Technique for the Surgical Treatment of Skull Base Tumors in Pediatric Patients

by Roberto Garcia-Navarrete, Alfonso Marhx-Bracho, Javier Terrazo-Lluch and José Luis Pérez-Gómez

Brain Sci. 2023, 13(6), 888; https://doi.org/10.3390/brainsci13060888 - 31 May 2023

Viewed by 3717

Abstract

The sphenoid ridge approach (SRA) was initially described as a surgical technique for treating vascular pathologies near the Sylvian fissure. However, limited studies have systematically explored the use of skull base techniques in pediatric patients. This study investigated an extended variation in the [...] Read more.

The sphenoid ridge approach (SRA) was initially described as a surgical technique for treating vascular pathologies near the Sylvian fissure. However, limited studies have systematically explored the use of skull base techniques in pediatric patients. This study investigated an extended variation in the sphenoid ridge approach (E-SRA), which systematically removed the pterion, orbital walls (roof and lateral wall), greater sphenoid wing, and anterior clinoid process to access the base of the skull. Objective: This report aimed to evaluate the advantages of the extradural removal of the orbital roof, pterion, sphenoid wing, and anterior clinoid process as a complement to the sphenoid ridge approach in pediatric patients. Patients and Methods: We enrolled 36 patients with suspected neoplastic diseases in different regions. The E-SRA was performed to treat the patients. Patients were included based on the a priori objective of a biopsy or a total gross resection. The surgical time required to complete the approach, associated bleeding, and any complications were documented. Results: Our results demonstrated that the proposed a priori surgical goal, biopsy, or resection were successfully achieved in all cases. In addition, using the E-SRA technique was associated with a shorter operative time, minimal bleeding, and a lower incidence of complications. The most frequently encountered complications were related to dural closure. Conclusions: The extended sphenoid ridge approach represents a safe and effective option for managing intracranial tumors in pediatrics. Full article

(This article belongs to the Special Issue Advances in Skull Base Tumor Surgery: The Practical Pearls)

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Surgical technique description of extended sphenoid ridge approach in pediatric patients. Full article ">Figure 2
A 6-year-old boy was treated with orbital Ewing’s sarcoma suspicion. (A) Pre-operative MRI shows an extraconal lesion extended medially until ethmoidal cells. (B) Post-operative MRI confirms the removal of tumoral tissue. Full article ">Figure 3
A graphic comparison of skin incision, craniotomy area, and orbital extension shows the benefits of the extended sphenoid ridge approach. (Modified models obtained from Atlas de Anatomía Humana Ver 2023.04.011. VISIBLE BODY®Argosy Publishing © 2007–2023). Full article ">Figure 4
A 12-year-old girl admitted with diabetes insipidus and a growth delay. (A) Pre-operative MRI shows a sellar mass with extension to the infundibular stalk. (B) Postoperative MRI shows a gross-total resection. Full article ">Figure 5
A 10-year-old girl with a history of headaches, visual disturbances, and panhypopituitarism. (A) Pre-operative MRI shows a mixed lesion with cystic and solid components. (B) A post-operative CT scan demonstrates the removal of tumoral tissue from sellar, parasellar, and suprasellar compartments. The histopathological analysis confirms the clinical suspicion of craniopharyngioma. Full article ">Figure 6
An 8-year-old girl with suspected optic pathway glioma was admitted. An E-SRA was performed and a sample biopsy was taken. The transoperative pathology study reported a germinal tumor. The image on the right shows the length of the skin incision behind the hair implantation. Full article ">

12 pages, 2588 KiB

Open AccessArticle

Endoscopic Endonasal Approach in Craniopharyngiomas: Representative Cases and Technical Nuances for the Young Neurosurgeon

by Jorge F. Aragón-Arreola, Ricardo Marian-Magaña, Rodolfo Villalobos-Diaz, Germán López-Valencia, Tania M. Jimenez-Molina, J. Tomás Moncada-Habib, Marcos V. Sangrador-Deitos and Juan L. Gómez-Amador

Brain Sci. 2023, 13(5), 735; https://doi.org/10.3390/brainsci13050735 - 28 Apr 2023

Cited by 2 | Viewed by 1818

Abstract

Craniopharyngiomas (CPs) are Rathke’s cleft-derived benign tumors originating most commonly in the dorsum sellae and representing 2% of intracranial neoplasms. CPs represent one of the more complex intracranial tumors due to their invasive nature, encasing neurovascular structures of the sellar and parasellar regions, [...] Read more.

Craniopharyngiomas (CPs) are Rathke’s cleft-derived benign tumors originating most commonly in the dorsum sellae and representing 2% of intracranial neoplasms. CPs represent one of the more complex intracranial tumors due to their invasive nature, encasing neurovascular structures of the sellar and parasellar regions, making its resection a major challenge for the neurosurgeon with important postoperative morbidity. Nowadays, an endoscopic endonasal approach (EEA) provides an “easier” way for CPs resection allowing a direct route to the tumor with direct visualization of the surrounding structures, diminishing inadvertent injuries, and providing a better outcome for the patient. In this article, we include a comprehensive description of the EEA technique and nuances in CPs resection, including three illustrated clinical cases. Full article

(This article belongs to the Special Issue Advances in Skull Base Tumor Surgery: The Practical Pearls)

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Axial (<bold>A</bold>) and coronal (<bold>B</bold>) T2-weighted MRI demonstrates a sellar lesion with suprasellar extension composed predominantly of a T2 hyperintense cystic component. Image (<bold>A</bold>) also shows dilatation of the left temporal horn of the lateral ventricle and postsurgical changes in both frontal lobules. In Image (<bold>B</bold>) the cystic and lobulated features of the lesion are seen. (<bold>C</bold>): Sagittal T1 weighted MRI image shows a hypointense cystic sellar lesion with upward displacement of the third ventricle. Full article ">Figure 2
Intraoperative images. (<bold>A</bold>) Drilling the sphenoidal rostrum. (<bold>B</bold>) Dural opening in cruciform fashion using no. 11 blade. (<bold>C</bold>) Dissection of the tumor borders away from the dura mater using a fine microdissector. (<bold>D</bold>) Tumor resection begins from the inferior and lateral components in order to avoid the superior component of the tumor that obstructs the surgeon’s view. (<bold>E</bold>) Hemostasis. (<bold>F</bold>) Multilayered reconstruction. Full article ">Figure 3
Axial (<bold>A</bold>), sagittal (<bold>B</bold>), and coronal (<bold>C</bold>) T1-post contrast MRI images show a mixed cystic-solid mass with a solid sellar, heterogeneously enhancing component, associated with a massive suprasellar and parasellar cystic, peripherally enhancing component extending upward into the third ventricle and displacing backwardly the brainstem. Axial, non-contrast CT (<bold>D</bold>) shows a hypodense sellar mass associated with massive peripheral calcifications. Full article ">Figure 4
Intraoperative images. (<bold>A</bold>) Drilling of the sellar floor using a diamond drill. (<bold>B</bold>) In this case it was necessary to remove the tuberculum sellae because of the tumor size, using a diamond drill and rongeurs. (<bold>C</bold>) Dural opening in a cruciform manner. (<bold>D</bold>) Dissection of tumor borders away from the durI (<bold>E</bold>) Tumor resection. (<bold>F</bold>) Multilayer reconstruction (In-lay fascia, gelfoam, fat tissue, On-lay fascia, nasoseptal flap, and fibrin glue). Full article ">Figure 5
Sagittal T2-weighted MRI image (<bold>A</bold>) shows a large sellar and suprasellar mass with components of different signal characteristics. An isointense component relative to brain parenchyma is located predominantly in the sellar region, which is associated with an hyperintense cystic component in its superior aspect. Axial (<bold>B</bold>) and coronal (<bold>C</bold>) T1-post contrast MRI image reveals a sellar and suprasellar mass, with areas of peripheral and central enhancement. In image (<bold>C</bold>), a constriction of the mass at the level of the diaphragma sellae is seen. Full article ">Figure 6
Intraoperative images. (<bold>A</bold>) Drilling of the sellar floor with a diamond drill. (<bold>B</bold>) Dural opening in a cruciform manner using a no. 11 blade. (<bold>C</bold>). Dissection of the tumor borders away from the dura, and, in this case, the cystic component was opened and suctioned. (<bold>D</bold>) Tumor resection of the lateral and superior parts until identification of the arachnoid layer Ip. (<bold>E</bold>) Hemostasis. (<bold>F</bold>) Multilayer reconstruction (fat tissue inside the sella, in-lay fascia lata, bone (gasket technique), on-lay fascia lata, and fibrin glue). Full article ">

Review

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17 pages, 71445 KiB

Open AccessEditor’s ChoiceReview

Operative Corridors in Endoscopic Skull Base Tumor Surgery

by A. Karim Ahmed, Nicholas R. Rowan and Debraj Mukherjee

Brain Sci. 2024, 14(3), 207; https://doi.org/10.3390/brainsci14030207 - 23 Feb 2024

Cited by 3 | Viewed by 1576

Abstract

Advances in technology, instrumentation, and reconstruction have paved the way for extended endoscopic approaches to skull base tumors. In the sagittal plane, the endonasal approach may safely access pathologies from the frontal sinus to the craniocervical junction in the sagittal plane, the petrous [...] Read more.

Advances in technology, instrumentation, and reconstruction have paved the way for extended endoscopic approaches to skull base tumors. In the sagittal plane, the endonasal approach may safely access pathologies from the frontal sinus to the craniocervical junction in the sagittal plane, the petrous apex in the coronal plane, and extend posteriorly to the clivus and posterior cranial fossa. This review article describes these modular extended endoscopic approaches, along with crucial anatomic considerations, illustrative cases, and practical operative pearls. Full article

(This article belongs to the Special Issue Advances in Skull Base Tumor Surgery: The Practical Pearls)

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14 pages, 3368 KiB

Open AccessReview

Jugular Foramen Tumors: Surgical Strategies and Representative Cases

by Andrea L. Castillo, Ali Tayebi Meybodi and James K. Liu

Brain Sci. 2024, 14(2), 182; https://doi.org/10.3390/brainsci14020182 - 17 Feb 2024

Cited by 2 | Viewed by 2098

Abstract

(1) Background: Jugular foramen tumors are complex lesions due to their relationship with critical neurovascular structures within the skull base. It is necessary to have a deep knowledge of the anatomy of the jugular foramen and its surroundings to understand each type of [...] Read more.

(1) Background: Jugular foramen tumors are complex lesions due to their relationship with critical neurovascular structures within the skull base. It is necessary to have a deep knowledge of the anatomy of the jugular foramen and its surroundings to understand each type of tumor growth pattern and how it is related to the surrounding neurovascular structures. This scope aims to provide a guide with the primary surgical approaches to the jugular foramen and familiarize the neurosurgeons with the anatomy of the region. (2) Methods and (3) Results: A comprehensive description of the surgical approaches to jugular foramen tumors is summarized and representative cases for each tumor type is showcased. (4) Conclusions: Each case should be carefully assessed to find the most suitable approach for the patient, allowing the surgeon to remove the tumor with minimal neurovascular damage. The combined transmastoid retro- and infralabyrinthine transjugular transcondylar transtubercular high cervical approach can be performed in a stepwise fashion for the resection of complex jugular foramen tumors. Full article

(This article belongs to the Special Issue Advances in Skull Base Tumor Surgery: The Practical Pearls)

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Figure 1
(A). Retrosigmoid C-shaped retroauricular skin incision posterior and parallel to the outline of the pinna (B). Combined approach right-sided C-shaped retro-auricular incision. The incision is started approximately 2 to 3 cm posterior to the upper border of the ear. It continues posteroinferiorly into the neck over the anterior border of the sternocleidomastoid muscle and under the mandibular angle. Full article ">Figure 2
(A) Lateral view of the combined transmastoid retro- and infralabyrinthine transjugular transcondylar transtubercular high cervical approach, reflecting the posterior fossa dura. The JB passing through the jugular foramen. The IJV descends along the ICA with the lower cranial nerves. The vertebral artery ascends through the transverse process of C1 and usually passes behind the atlantal condyle. (B) Extracranial transcervical perspective of the glossopharyngeal, vagus, accessory, and hypoglossal nerves. The IX and XII nerve pass anteriorly along the lateral surface of the ICA. The XI nerve descends posteriorly across the lateral surface of the IJV. The vagus descends inferiorly within the carotid sheath. AC., atlantal Condyle. C1., atlas. ECA., external carotid artery. HC., hypoglossal canal. ICA., internal carotid artery. IJV., internal jugular vein. JB., jugular bulb. JT., jugular tubercule OC., occipital condyle. PFD., posterior fossa dura. SS., sigmoid sinus. VA., vertebral artery. VII., facial nerve. XI., accessory nerve. IX., glossopharyngeal nerve. X., vagus nerve. XII., hypoglossal nerve. Full article ">Figure 3
(A). Intradural and extradural views of the lower cranial nerves passing through the jugular foramen. The glossopharyngeal, vagus, and accessory nerves arise from the medulla in the postolivary sulcus and pierce the dural roof of the jugular foramen to pass through it. The IX nerve enters the jugular foramen through the glossopharyngeal meatus, and the X and XI nerves through the vagus meatus. The PICA arises from the posterior or lateral surfaces of the VA. The XII exits through the hypoglossal canal above the OC. (B) Final view of the combined approach with high cervical exposure. From the intradural perspective, the lower cranial nerves leaving the medulla and enter the jugular foramen. Hypoglossal nerve exits through the hypoglossal canal. Vertebral artery below the OC. Sigmoid sinus empties into the jugular foramen after coursing down the sigmoid sulcus, crossing the occipitomastoid suture at the site of the jugular bulb. From the jugular bulb, the flow is directed downward into the IJV. AC., atlantal condyle ICA., internal carotid artery., IJV., internal jugular vein. JB., jugular bulb. JT., jugular tubercule. OC., occipital condyle., PICA., postero-inferior cerebellar artery. SS., sigmoid sinus. VA., vertebral artery. VII., facial nerve. IX., glossopharyngeal nerve. X., vagus nerve. XI., accessory nerve. XII., hypoglossal nerve. Full article ">Figure 4
Pre-op and Post-op MRI demonstrating a left jugular paraganglioma (glomus jugulare). (A,B) The images show a large jugular paraganglioma that invaded into the cervical IJV and had significant extension intradurally into the cerebellopontine angle with compression of the brainstem. (C,D) The images show gross total resection of the tumor by the combined transmastoid retro- and infralabyrinthine transjugular transcondylar transtubercular high cervical approach. Full article ">Figure 5
Pre-operative and post-operative MRI views of a left jugular foramen meningioma invading the internal jugular vein. (A,B) The images show T1 gadolinium- enhanced images of a homogenous mass in the jugular foramen with intradural extension. (C,D) The images show gross total resection of the tumor by the combined transmastoid retro- and infralabyrinthine transjugular transcondylar trans tubercular high cervical approach. Full article ">Figure 6
(A) Left-sided exposure of jugular foramen via extended anterolateral infralabyrinthine transjugular approach for resection of jugular foramen meningioma. (B) After tying off the IJV and endoluminal occlusion of the sigmoid sinus, the lateral wall of the sigmoid sinus, jugular bulb and internal jugular vein are excised to expose the intraluminal tumor in the jugular bulb. (C,D) Retrosigmoid exposure of the intradural portion of the tumor at the jugular fossa. The tumor is carefully dissected from the lower cranial nerves. ICA., internal carotid artery. IJV., internal jugular vein. PFD., posterior fossa dura. SS., sigmoid sinus. T., tumor. Full article ">Figure 7
Pre-op and Post-op MRI views of an extensive cranio-cervical chordoma invading the jugular foramen, cerebello-medullary cistern and parapharyngeal space. (A–C) The images show a T2 MRI signal with a large lobulated mass centered on the right parapharyngeal space with intradural and extradural extension. The tumor is compressing the anterior pons and the airway deviated to the left side. (D–F) The images show a gross total resection of the tumor using the combined transmastoid retro- and infralabyrinthine transjugular transcondylar transtubercular high cervical approach. Full article ">Figure 8
Pre-op and post-op MRI views of a jugular foramen schwannoma. (A,B) The images show a gadolinium enhanced T1 weighted MR images with a well- circumscribed dumbbell shaped Schwannoma invading the jugular foramen. (C,D) The images show gross total resection of the tumor using a combined transmastoid retro- and infralabyrinthine transjugular transcondylar transtubercular high cervical approach. Full article ">

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10 pages, 2237 KiB

Open AccessCase Report

Two-Stage Surgical Management for Acutely Presented Large Vestibular Schwannomas: Report of Two Cases

by Abdullah Keles, Burak Ozaydin, Ufuk Erginoglu and Mustafa K. Baskaya

Brain Sci. 2023, 13(11), 1548; https://doi.org/10.3390/brainsci13111548 - 4 Nov 2023

Viewed by 1619

Abstract

The surgical management of vestibular schwannomas should be based on their presentation, neuro-imaging findings, surgeons’ expertise, and logistics. Multi-stage surgery can be beneficial for large-sized lesions with acute presentations. Herein, we highlighted the indications for two cases managed initially through the retrosigmoid and, [...] Read more.

The surgical management of vestibular schwannomas should be based on their presentation, neuro-imaging findings, surgeons’ expertise, and logistics. Multi-stage surgery can be beneficial for large-sized lesions with acute presentations. Herein, we highlighted the indications for two cases managed initially through the retrosigmoid and, subsequently, translabyrinthine approaches. The first case presented with acute balance and gait issues and a long history of hearing loss and blurred vision. Neuroimaging findings revealed a cerebellopontine angle lesion, resembling a vestibular schwannoma, with significant brainstem compression and hydrocephalus. Due to the rapidly deteriorating clinical status and large-sized tumor, we first proceeded with urgent decompression via a retrosigmoid approach, followed by gross total resection via a translabyrinthine approach two weeks later. The second case presented with gradually worsening dizziness and hemifacial numbness accompanied by acute onset severe headaches and hearing loss. Neuroimaging findings showed a large cerebellopontine angle lesion suggestive of a vestibular schwannoma with acute intratumoral hemorrhage. Given the acute clinical deterioration and large size of the tumor, we performed urgent decompression with a retrosigmoid approach followed by gross total resection through a translabyrinthine approach a week later. Post-surgery, both patients showed excellent recovery. When managing acutely presented large-sized vestibular schwannomas, immediate surgical decompression is vital to avoid permanent neurological deficits. Full article

(This article belongs to the Special Issue Advances in Skull Base Tumor Surgery: The Practical Pearls)

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14 pages, 10021 KiB

Open AccessCase Report

Staged Strategies to Deal with Complex, Giant, Multi-Fossa Skull Base Tumors

by Brandon Edelbach and Miguel Angel Lopez-Gonzalez

Brain Sci. 2023, 13(6), 916; https://doi.org/10.3390/brainsci13060916 - 6 Jun 2023

Viewed by 1706

Abstract

Given the complex and multifaceted nature of resecting giant tumors in the anterior, middle, and, to a lesser extent, the posterior fossa, we present two example strategies for navigating the intricacies of such tumors. The foundational premise of these two approaches is based [...] Read more.

Given the complex and multifaceted nature of resecting giant tumors in the anterior, middle, and, to a lesser extent, the posterior fossa, we present two example strategies for navigating the intricacies of such tumors. The foundational premise of these two approaches is based on a two-stage method that aims to improve the visualization and excision of the tumor. In the first case, we utilized a combined endoscopic endonasal approach and a staged modified pterional, pretemporal, with extradural clinoidectomy, and transcavernous approach to successfully remove a giant pituitary adenoma. In the second case, we performed a modified right-sided pterional approach with pretemporal access and extradural clinoidectomy. This was followed by a transcortical, transventricular approach to excise a giant anterior clinoid meningioma. These cases demonstrate the importance of performing staged operations to address the challenges posed by these giant tumors. Full article

(This article belongs to the Special Issue Advances in Skull Base Tumor Surgery: The Practical Pearls)

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