Clinical Outcomes of Extended Endoscopic Endonasal Approach for The Resection of Anterior Skull Base Meningiomas.

The early experience of treating anterior skull base meningiomas with intra-extracranial extension via pure endoscopic endonasal approach (EEA) was presented, the safety, feasibility and preliminary treatment outcomes were investigated. Eight patients with intra-extradural meningiomas who were admitted from October 2006 to October 2010 were operated on via EEA in one stage in Xuanwu hospital. In this study, the operative technique was described, the degree of resection, complications and the early clinical outcomes were discussed. The complete resection of meningiomas with intra-extracranial extension was achieved in all patients using EEA in one stage. Preoperative visual symptoms were improved or resolved in all cases who presented with preoperative visual complaints. No patient in our series experienced a new neurological deficit after surgery or recurrence and death related meningiomas in the follow-up period (33-75 months). One patient experienced postoperative cerebrospinal fluid leak, delayed meningitis and secondary hydrocephalus which responded to therapy. After treatment, the patient was cure. Our limited experience indicates that EEA is feasible and safe for the complete resection of anterior skull base meningiomas with intra- and extracranial extension in one stage in selected cases.

Meningiomas of the anterior skull base are attractive tumors for resection via an endoscopic endonasal route. The use of the vascularized Hadad-Bassagasteguy nasoseptal flap has dramatically reduced the cerebrospinal fluid (CSF) leak rate-the veritable Achilles heel of this surgical approach. Benign meningiomas, however, can erode through the nasal mucosa-the very same mucosa that is used to reconstruct the anterior cranial fossa floor. The goal of this study was to describe the presence of meningioma invasion into the mucosa in patients who underwent endoscopic endonasal resection of ventral skull base meningiomas. The implications of this finding are discussed with respect to resection, reconstruction, and recurrence. This is a retrospective review of three patients who underwent endoscopic endonasal complete resection of ventral skull base meningiomas. Surgically excised tissues were processed for routine histopathological analysis. A complete resection of the bone, dura, and tumor was performed in all three cases. Both patients with visual deficits improved. The first patient to undergo endoscopic surgical resection developed a CSF leak, but the later two patients with larger tumors did not. Histopathological analysis demonstrated mucosal invasion by World Health Organization (WHO) grade I meningioma in two of the three cases. Ventral anterior skull base meningiomas can invade through bone into the mucosa. Because the endoscopic endonasal resection of these meningiomas often requires the use of a vascularized nasoseptal flap to minimize CSF leak complications, it is possible that the nasoseptal flap itself may be compromised by tumor tissue. The creation of the nasoseptal flap should take the findings of this study into consideration to minimize late recurrence.

Introduction: Endoscopic endonasal techniques are increasingly common in a variety of skull base lesions. A major obstacle that remains to be addressed within the field is sinonasal symptomatology following endoscopic repair, with a paucity of literature describing such outcomes following resection of large anterior skull base (ASB) meningiomas. Herein, we describe our institutional experiences utilizing SNOT-22 scoring in a series of ASB meningiomas treated via an endoscopic endonasal approach.

Minimally invasive endoscope-assisted approaches to the anterior skull base offer an alternative to traditional open craniotomies. Given the restrictive operative corridor, appropriate case selection is critical for success. In this paper, the authors present the results of three different minimal access approaches to meningiomas of the anterior and middle fossae and examine the differences in the target areas considered appropriate for each approach, as well as the outcomes, to determine whether the surgical goals were achieved. A consecutive series of the endoscopic endonasal approach (EEA), supraorbital approach (SOA), or transorbital approach (TOA) for newly diagnosed meningiomas of the anterior and middle fossa skull base between 2007 and 2022 were examined. Probabilistic heat maps were created to display the distribution of tumor volumes for each approach. Gross-total resection (GTR), extent of resection, visual and olfactory outcomes, and postoperative complications were assessed. Of 525 patients who had meningioma resection, 88 (16.7%) were included in this study. EEA was performed for planum sphenoidale and tuberculum sellae meningiomas (n = 44), SOA for olfactory groove and anterior clinoid meningiomas (n = 36), and TOA for spheno-orbital and middle fossa meningiomas (n = 8). The largest tumors were treated using SOA (mean volume 28 ± 29 cm3), followed by TOA (mean volume 10 ± 10 cm3) and EEA (mean volume 9 ± 8 cm3) (p = 0.024). Most cases (91%) were WHO grade I. GTR was achieved in 84% of patients (n = 74), which was similar to the rates for EEA (84%) and SOA (92%), but lower than that for TOA (50%) (p = 0.002), the latter attributable to spheno-orbital (GTR: 33%) not middle fossa (GTR: 100%) tumors. There were 7 (8%) CSF leaks: 5 (11%) from EEA, 1 (3%) from SOA, and 1 (13%) from TOA (p = 0.326). All resolved with lumbar drainage except for 1 EEA leak that required a reoperation. Minimally invasive approaches for anterior and middle fossa skull base meningiomas require careful case selection. GTR rates are equally high for all approaches except for spheno-orbital meningiomas, where alleviation of proptosis and not GTR is the primary goal of surgery. New anosmia was most common after EEA.

Introduction: Large anterior skull base (ASB) meningiomas are occasionally highly vascular, and are supplied predominantly by the anterior and posterior ethmoidal arteries which are branches of the ophthalmic artery. Effective preoperative embolization of these lesions is thwarted by concerns of retrograde embolization of the ophthalmic artery with visual loss or blindness. The standard goal of early intraoperative devascularization of these meningiomas at the basal dural attachment is often difficult until there has been substantial tumor decompression. As such, resection of these lesions is often coupled with lengthy operative times and significant blood loss. Endoscopic transnasal approaches provide direct access to the ethmoidal arteries, and ASB meningiomas are largely devascularized early on in the course of surgical resection. However, endoscopic resection of larger ASB meningiomas has been associated with lengthy resection times, subtotal resection, and increased rate of postoperative CSF leak. In an effort to decrease operative time and blood loss we have adopted a surgical strategy that incorporates endoscopic transnasal devascularization of the tumor as a means to complement the strengths of an open surgical approach. We present our institutional experience with two cases in which we treated large (>4 cm) ASB meningiomas with a combined approach—endoscopic transnasal sacrifice of the anterior and posterior ethmoidal arteries followed by open subfrontal resection.

Efficiency and Safety of Autologous Fat Grafts in Reconstructing Skull Base Defects After Resection of Skull Base Meningiomas

Endoscopic endonasal approaches (EEAs) to anterior skull base meningiomas have grown in popularity, though anatomic limitations remain unclear. To show the anatomic limits of EEA for meningiomas. Retrospective chart review for all patients that underwent EEA for anterior skull base meningiomas from 2005 to 2014. A total of 100 patients averaged follow-up of 46.9 mo (24-100 mo). A total of 35 patients (35%) had olfactory groove, 33 planum sphenoidale (33%), and 32 tuberculum sella (32%) meningiomas. The average diameter was 2.9 cm (0.5-8.1 cm). Vascular encasement was seen in 11 patients (11%) and calcification in 20 (20%). Simpson Grade 1 (SG1) resection was achieved in 64 patients (64%). Only calcification impacted degree of resection (40% SG1, P=.012). The most common residual was on the anterior clinoid dura (11 patients [11%]). Six (6%) had residual superior/lateral to the optic nerve. Residual tumor was adherent to the optic apparatus or arteries in 5 patients (5%) each, and 3 patients (3%) had residual lateral to the mid-orbit. Rates of residual decreased over time. A total of 11 patients (11%) had tumor recurrence (mean of 40 mo): 4 (4%) on the anterior clinoid, 2 (2%) each on the lateral orbital roof, adherent to optic apparatus and superolateral to the optic nerve, and 1 (1%) was at the anterior falx. Anterior skull base meningiomas can effectively be approached via EEA in most patients; tumors extending to the anterior clinoid, anterior falx, or superolateral to the optic nerve or orbital roof, especially if calcified, may be difficult to reach via EEA.

Introduction Here we systematically review the extant literature to highlight the advantages of bilateral versus unilateral approaches and endoscopic endonasal (midline) approaches versus transcranial approaches for olfactory groove meningiomas, focusing on complications, extent of resection, and local recurrence rates. Methods Three databases were queried to identify all primary prospective trials and retrospective series comparing outcomes following endoscopic endonasal versus transcranial approaches and unilateral versus bilateral craniotomy for surgical resection of olfactory groove meningiomas. All articles were screened by two independent authors and selected for formal analysis according to predefined inclusion/exclusion criteria. Results Seven studies comprising 288 total patients (mean age 55.0 ± 24.6 years) met criteria for inclusion. In the three comparing the endoscopic endonasal ( n = 21) versus transcranial ( n = 32) approaches, there was no significant difference between the two with respect to gross total resection ( p = 0.34) or rates of Simpson Grade 1 resection ( p = 0.69). EEA demonstrated higher rates of overall complications ( p < 0.01) including postoperative infection ( p = 0.03). In the four studies comparing bilateral ( n = 117) versus unilateral approaches ( n = 118), overall complication rates ( p < 0.01) and disease recurrence ( p = 0.01) were higher with bilateral approaches. All surgery-related mortalities also occurred in the bilateral cohort ( n = 7, 7.14%). Gross total resection ( p = 0.63) and Simpson grade ( p = 0.48) were comparable between approaches. Olfaction preservation was superior for unilateral approaches ( p < 0.01). Conclusion Though the literature is limited, current evidence suggests that the endoscopic endonasal approach may be favorable over conventional craniotomy for select olfactory groove meningioma patients. Where craniotomy is used, unilateral approaches appear to reduce complications and the risk of olfaction loss.

Midline ventral skull base meningiomas may be amenable to an endonasal endoscopic approach, which has theoretical advantages and may help preserve quality of life (QOL) when compared with transcranial approaches. To investigate the effect of age on QOL following endonasal endoscopic surgery, given the documented impact of age on QOL outcomes following transcranial resection of midline ventral skull base meningiomas. We reviewed a prospectively acquired database of endonasal endoscopic surgery for meningiomas. Inclusion criteria included patients who had completed long-term postoperative (≥6 months follow-up) QOL questionnaires (Anterior Skull Base Questionnaire [ASBQ] and Sino-Nasal Outcome Test [SNOT-22]). Postoperative QOL scores were also compared with preoperative QOL in a patient subset. Long-term QOL data were available in 34 patients. Average postoperative ASBQ and SNOT-22 scores were 3.39 and 23.0, respectively. Better QOL was statistically associated with age <55 (P = .02). In a subset of patients, preoperative and postoperative ASBQ and SNOT-22 scores were compared. Only SNOT-22 scores significantly increased from 15.9 + 20.8 to 25.9 + 19.5 (P = .04). We report the first study specifically evaluating long-term QOL after endonasal endoscopic resection of skull base meningiomas. QOL was decreased postoperatively in patients aged ≥55. ASBQ, Anterior Skull Base QuestionnaireGTR, gross total resectionQOL, quality of lifeSNOT-22, 22-item Sino-Nasal Outcome Test.

P.3.014 - Cytochrome P450 polymorphisms moderate pharmacokinetics and pharmacodynamic effects of MDMA in healthy subjects

Here, we introduced our short experience on the application of a new CUSA Excel ultrasonic aspiration system, which was provided by Integra Lifesciences corporation, in skull base meningiomas resection. Ten patients with anterior, middle skull base and sphenoid ridge meningioma were operated using the CUSA Excel ultrasonic aspiration system at the Neurosurgery Department of Shanghai Huashan Hospital from August 2014 to October 2014. There were six male and four female patients, aged from 38 to 61 years old (the mean age was 48.5 years old). Five cases with tumor located at anterior skull base, three cases with tumor on middle skull base, and two cases with tumor on sphenoid ridge. All the patents received total resection of meningiomas with the help of this new tool, and the critical brain vessels and nerves were preserved during operations. All the patients recovered well after operation. This new CUSA Excel ultrasonic aspiration system has the advantage of preserving vital brain arteries and cranial nerves during skull base meningioma resection, which is very important for skull base tumor operations. This key step would ensure a well prognosis for patients. We hope the neurosurgeons would benefit from this kind of technique.

Surgical Anatomy for Control of Ethmoidal Arteries During Extended Endoscopic Endonasal or Microsurgical Resection of Vascular Anterior Skull Base Meningiomas

Background: Keyhole-based approaches are being explored for skull base tumor surgery; aiming for reduced complications while maintaining resection success rates. This study evaluates skull base meningiomas resected using an endoscopic-assisted microsurgical keyhole approach, comparing outcomes with standard procedures. Methods: Between 2013 and 2019; 71 out of 89 patients were treated using an endoscopic-assisted microsurgical procedure. A total of 42 meningiomas were localized at the anterior skull base and 29 in the posterior fossa. The surgical techniques and use of an endoscope were analyzed and compared in terms of complications, surgical radicality, outcome, and recurrences in the patients' follow-up. Results: The two different cohorts yielded similar rates of GTR (anterior skull base: 80% versus posterior fossa: 82%). The complication rate was 31% for the posterior fossa and 16% for the anterior skull base. An endoscope was used in 79% of all cases. Tumor remnants were detected by means of endoscopic visualization in 58.6% of posterior fossa and 33% of anterior skull base meningiomas. The statistical analysis revealed significantly higher benefits from endoscope use in the posterior fossa cohort (p < 0.05). Conclusions: The results revealed that endoscopy was beneficial in both locations. The identification of remnant tumor tissue and the benefit of endoscopy were clearly higher in the posterior fossa. Endoscopic assistance is a very helpful tool for increasing radicality, providing a better anatomical overview during surgery, and better identifying remnant tumor tissue in skull base meningioma surgery.

Indications and Limitations of the Endoscopic Endonasal Approach for Anterior Cranial Base Meningiomas

Resection of large anterior midline skull base meningiomas with extensive peritumoral edema poses high risks due to postoperative edema decompensation leading to increased intracranial pressure. Initial craniectomy prevents intracranial pressure decompensation but requires secondary cranioplasty. This study compares single-stage osteoplastic craniotomy with tumor resection to a two-stage approach using bifrontal craniectomy, tumor resection and subsequent cranioplasty after edema recovery in a second surgical step. Patients with large anterior midline skull base meningiomas (> 50 mm) and extensive peritumoral edema were included. Group 1 underwent single-stage resection (2002–2016), while Group 2 had a two-stage approach (2012–2022). The primary outcome was the Karnofsky Performance Scale (KPS) at three months post-surgery. Secondary outcomes included preoperative KPS, KPS at discharge and last follow-up, ICU stay, hospital stay length and complication rates. A total of 25 patients were analyzed (Group 1: n = 9; Group 2: n = 16). Group 2 demonstrated significantly improved KPS at three months postoperatively (median KPS 70% vs. 50%; p = 0.0204) with a non-significant reduction in ICU stay (10 vs. 6.5 days; p = 0.3284). Although no significant differences were observed in KPS at discharge (Group 1: KPS 30% vs. Group 2: KPS 50%; p = 0.1829) or last follow-up (Group 1: KPS 60% vs. Group 2: KPS 80%; p = 0.1630), Group 2 patients required fewer postoperative interventions for complications unrelated to cranioplasty. Overall complication rates were comparable in both groups (Group 1: 67% vs. Group 2: 56%; p = 0.6274). Two-stage resection of large anterior midline skull base meningiomas with extensive edema provides superior clinical outcomes at three months postoperatively without increasing overall complication rates. These findings support the use of a two-stage surgical strategy for highly selected patients. However, further multicenter studies are warranted to validate these results in larger cohorts.