The endoscopic endonasal approach is not superior to the microscopic transcranial approach for anterior skull base meningiomas\u2014a meta-analysis

Ivo S Muskens,Joseph P Castlen,Rania A Mekary,Amir H Zamanipoor Najafabadi,Linda S Aglio,Wouter R Van Furth,Timothy R Smith,Marike L D Broekman,Vanessa Briceno,Tom L Ouwehand,William B Gormley

doi:10.1007/s00701-017-3390-y

Abstract

ObjectIn the past decade, the endonasal transsphenoidal approach (eTSA) has become an alternative to the microsurgical transcranial approach (mTCA) for tuberculum sellae meningiomas (TSMs) and olfactory groove meningiomas (OGMs). The aim of this meta-analysis was to evaluate which approach offered the best surgical outcomes.MethodsA systematic review of the literature from 2004 and meta-analysis were conducted in accordance with the PRISMA guidelines. Pooled incidence was calculated for gross total resection (GTR), visual improvement, cerebrospinal fluid (CSF) leak, intraoperative arterial injury, and mortality, comparing eTSA and mTCA, with p-interaction values.ResultsOf 1684 studies, 64 case series were included in the meta-analysis. Using the fixed-effects model, the GTR rate was significantly higher among mTCA patients for OGM (eTSA: 70.9% vs. mTCA: 88.5%, p-interaction < 0.01), but not significantly higher for TSM (eTSA: 83.0% vs. mTCA: 85.8%, p-interaction = 0.34). Despite considerable heterogeneity, visual improvement was higher for eTSA than mTCA for TSM (p-interaction < 0.01), but not for OGM (p-interaction = 0.33). CSF leak was significantly higher among eTSA patients for both OGM (eTSA: 25.1% vs. mTCA: 10.5%, p-interaction < 0.01) and TSM (eTSA: 19.3%, vs. mTCA: 5.81%, p-interaction < 0.01). Intraoperative arterial injury was higher among eTSA (4.89%) than mTCA patients (1.86%) for TSM (p-interaction = 0.03), but not for OGM resection (p-interaction = 0.10). Mortality was not significantly different between eTSA and mTCA patients for both TSM (p-interaction = 0.14) and OGM resection (p-interaction = 0.88). Random-effect models yielded similar results.ConclusionIn this meta-analysis, eTSA was not shown to be superior to mTCA for resection of both OGMs and TSMs.

Highlights

The mainstay of treatment for tuberculum sellae meningiomas (TSMs) and olfactory groove meningiomas (OGMs) is surgery
In this meta-analysis, endoscopic transsphenoidal approach (eTSA) was not shown to be superior to microscopic transcranial approach (mTCA) for resection of both OGMs and TSMs
Future improvement of the instruments used (e.g., 3D endoscopes or glues) may improve the results obtained by eTSA over time [33]. This meta-analysis indicates that the endoscopic transsphenoidal approach has not been shown to be superior to the microscopic transsphenoidal approach for either olfactory groove meningiomas (OGMs) or tuberculum sellae menigniomas (TSMs)

Summary

Introduction

The mainstay of treatment for tuberculum sellae meningiomas (TSMs) and olfactory groove meningiomas (OGMs) is surgery. TSMs and OGMs are resected using a microscopic transcranial approach (mTCA). As a result of the evolution of endoscopic surgery for pituitary adenomas, these meningiomas have been increasingly resected using an endonasal endoscopic transsphenoidal approach (eTSA), as first described by Jho et al in 2004 [38]. The endoscopic approach is generally viewed as less invasive, with some studies suggesting that eTSA caused fewer postoperative changes on magnetic resonance imaging (MRI) compared to mTCA possibly indicating less manipulation [22], it has been suggested that eTSA results in higher rates of CSF leaks and potentially different outcomes (e.g., less GTR) [18, 42]. The aim of this systematic review and meta-analysis was to evaluate which approach (eTSA vs. mTCA) offers the best surgical outcomes

Results

Discussion

Conclusion