Maximal Resection of Tumors Encasing the Internal Carotid Artery and Hindering Internal Carotid Artery Expansion Followed by Revascularization Surgery: A Series of Nine Cases at a Single Tertiary Center.

Yuming Sun,Fangjun Liu,Xiangen Shi,Long Wang

doi:10.3389/fsurg.2022.808446

Yuming Sun, Fangjun Liu + Show 2 more

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https://doi.org/10.3389/fsurg.2022.808446

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Abstract

PurposeCerebral reconstruction appears to play a diminished role in managing complex skull base tumors involving vital neurovascular structures.Materials and MethodsPatients with recurrent or progressive middle cranial fossa tumors treated by radical resection followed by extracranial-to-intracranial (EC-IC) bypass from 2014 to 2019 were included. Balloon test occlusion (BTO) was performed preoperatively.ResultsOverall, 9 patients (5 males, 4 females; mean age, 29.9 years) were enrolled. The lesions arose from the parasellar region (3), cavernous sinus (3), petroclival region (2), or orbital apex (1), and all encased the cavernous/petrous portion of the internal carotid artery. Before tumor resection, internal maxillary artery (IMA) bypass was performed for 7 patients, cervical EC-IC bypass was performed for 1 patient, and interposed superficial temporal artery (STA) bypass was performed for 1 patient. BTO failed in 8 patients and was tolerated by one patient. Intraoperative blood flow of the interposed graft was 79.7 ± 37.86 ml/min after IMA bypass, 190.6 ml/min following cervical EC-IC bypass and 75 ml/min after interposed STA bypass. All bypasses were patent on intraoperative indocyanine green angiography. Radical tumor resection was achieved in 5 patients (55.6%), and patency was confirmed postoperatively in 88.8% (8/9) of bypasses. Six patients showed favorable outcomes at discharge. At the 2-year follow-up, 7 patients (77.8%) had favorable outcomes (Karnofsky Performance Scale score>80). At the 1.5-year follow-up, one patient had died due to infarction; at the 3-year follow-up, another patient had developed tumor recurrence despite being asymptomatic.ConclusionCerebral bypass remains a vital tool for managing select middle cranial fossa tumors that invade or erode the surrounding neurovasculature or hinder carotid artery expansion and are difficult to resect.

Highlights

The majority of reports [1,2,3] on middle cranial fossa tumors have described the increased use of the endoscopic endonasal approach (EEA), but this treatment is still unsatisfactory for patients with tumor encasement or invasion of the cavernous/petrous portions of the internal carotid artery (ICA) [4, 5]
9 patients, accounting for 1.4% of 621 patients surgically treated for middle fossa floor or sellar region tumors, underwent maximal resection of middle cranial fossa tumors followed by bypass surgery
We retrospectively reviewed 9 patients with recurrent or progressive middle cranial fossa tumors encasing or invading the ICA and were treated from 2014 to 2019

Summary

Introduction

The majority of reports [1,2,3] on middle cranial fossa tumors have described the increased use of the endoscopic endonasal approach (EEA), but this treatment is still unsatisfactory for patients with tumor encasement or invasion of the cavernous/petrous portions of the internal carotid artery (ICA) [4, 5]. In this series, 9 patients, accounting for 1.4% of 621 patients surgically treated for middle fossa floor or sellar region tumors, underwent maximal resection of middle cranial fossa tumors followed by bypass surgery. After the carotid artery bypass, the complex middle cranial fossa tumors encasing/invading the ICA were maximally removed, thereby minimizing surgical difficulty

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