Anterior Fossa Meningiomas Research Articles

Exploring the Potential Use of Virtual Reality with a Supraorbital Keyhole Craniotomy for Anterior Skull Base Meningiomas: Two Case Reports

Introduction: A supraorbital keyhole craniotomy (SOKC) is a novel alternative to frontal craniotomies for accessing the anterior fossa for resecting tumors and clipping aneurysms; however, its implementation is limited in patients at a high risk of complications. We present two cases involving the use of augmented reality (AR) and virtual reality (VR) for patient selection and preoperative planning for a supraorbital tumor resection of anterior fossa meningiomas. Methods: This is a prospective, single-center case series at a research institute. We identified patients with an anterior or middle fossa meningioma regardless of age, gender, and tumor characteristics who could undergo an SOKC and MRI. The preoperative planning was performed with the BrainLab Magic Leap AR/VR platform. The meningiomas were resected through the SOKC under neuronavigation. Results: We identified two cases: a 37-year-old male with a meningioma in the sellar region and an 84-year-old male with a right anterior fossa meningioma, both confirmed by MRI. Both patients had a complete tumor resection by a minimally invasive SOKC after preoperative planning with the AR/VR platform. Postoperatively, hyponatremia complicated the first case, while the second case developed an intracranial hemorrhage. They both recovered after the appropriate interventions. Conclusions: The use of an SOKC for anterior skull base meningiomas should be individualized after considering the lesion characteristics, vascular control needs, and the surgeon’s expertise. VR/AR-assisted preoperative evaluation and planning will optimize the patient selection and surgical outcomes. We can utilize VR/AR technologies to identify patients that will benefit from an SOKC and expand the implementation of the approach beyond its current limitations.

Fully endoscopic transcranial removal of anterior fossa meningioma through the minipterional keyhole approach in case with marked frontal sinuous pneumatization: clinical case

Transcranial surgery of skull base meningiomas currently remains the main method of treatment. Transnasal removal is possible in a number of cases, but it is associated with the risk of postoperative CSF-leak as a result of insolvency of the reconstruction of the skull base defect. Minimally invasive (keyhole) accesses provide a tumor overview comparable to standard accesses in most cases. The anterior-medial part of the anterior cranial fossa and the olfactory fossa is not accessible to the direct view from the minipterional craniotomy. The use of angular endoscopic optics in combination with additional resection or thinning of the bones in the orbital roof provides an overview sufficient to remove the tumor, but manipulations in this area require the use of specific tools. Aspirators, dissectors and coagulators should have bends of different expressions. The application of the described technique is advisable only in certain specially selected cases.

Endoscopic Endonasal Transsphenoidal Approach for Resection of Tuberculum Sella and Planum Sphenoidale Meningiomas: A Snapshot of Our Institutional Experience.

Introduction:Meningiomas of the tuberculum sellae and planum sphenoidale represent a subgroup of anterior skull base tumors that comprise approximately 5%–10% of all intracranial meningiomas. Most of the patients report with failing vision, so early surgical decompression either transcranial and/or endonasal approach is recommended. The endonasal route allows for direct coagulation of the tumor meningeal supply and extensive resection of dural attachments, and importantly, provides an inferior to superior access to the infrachiasmatic region that facilitates complete tumor removal without encountering the optic nerve. This article describes our institutional experience for the endonasal resection of tuberculum sellae and planum sphenoidale meningiomas.Materials and Methods:We retrospectively analyzed eight cases of tuberculum sellae and planum sphenoidale meningiomas who selectively underwent endoscopic endonasal transsphenoidal resection between 2015 and 2018. All patients had ophthalmological, endocrinological, and radiological evaluation both preoperatively and postoperatively.Results:Among the study group, we found age range 22–68 years, male:female 1:2. Among the radiological findings, there were five cases of tuberculum sellae meningioma, while three cases were of planum sphenoidale meningioma. In tumor resection status, we found gross total resection in six cases and debulking in two cases. Postoperative analysis of visual outcome revealed improvement in four cases, constant in three cases, and worsening in one case. We also found the post of nasal complications in four cases, cerebrospinal fluid leak in two cases and transient diabetes insipidus in one case.Conclusion:In this study, we highlighted our experience of a very small group of patients with anterior fossa meningioma specific to tuberculum sella and planum sphenoidale origin.

Little Insights from Big Data: Cerebrospinal Fluid Leak After Skull Base Surgery and the Limitations of Database Research

Cerebrospinal fluid (CSF) leak is a frustrating complication of skull base surgery. Published methodologies using national surgical databases to assess CSF leak have not accounted for variability between skull base operations. Our goal was to attempt the development of a novel framework for adapting big data techniques to skull base surgery and assess the reliability of corresponding data manipulations. A retrospective nested case-control analysis was performed using patients from the National Surgical Quality Improvement Program (NSQIP) registry, 2012-2015. Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes identified possible skull base operations, which were systematically grouped by anatomic location. Meningioma, schwannoma, pituitary adenoma, and trigeminal neuralgia (TN) were included. Of 2918 patients, 84 (2.9%) were readmitted/reoperated on within 30 days for CSF leak. Operations involving the anterior fossa, both middle/posterior fossas in 1 approach, or the orbitocranial zygomatic approach were significantly associated with CSF leak, as were schwannomas and meningiomas in any location (8.5%, 3.1%, 10.2%, 4.1%, and 3.0%; all P < 0.0001). Multivariate analysis of only middle/posterior fossa lesions identified schwannoma (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.3-5.6; P= 0.008), TN (OR, 5.4; 95% CI, 2-14.7; P= 0.008), chronic obstructive pulmonary disease (OR, 3.9; 95% CI, 1.1-14; P= 0.03), and increased operative time (OR, 4.0; 95% CI, 1.7-9.5; P= 0.009) as significant CSF leak risk factors. Based on NSQIP data analyzed using a rational skull base/anatomic framework, risk factors for postoperative CSF leak include chronic obstructive pulmonary disease, operative time, anterior fossa meningioma, and middle/posterior fossa schwannoma or TN. Although databases such as NSQIP can be extensively manipulated to generate surrogate results that may provide limited insight, applications beyond their design should be approached carefully.

Preservation of olfaction in anterior midline skull base meningiomas: a comprehensive approach.

Olfaction is an undervalued sense in neurosurgery. Attempted surgical resection of anterior cranial fossa meningiomas puts the olfactory pathway at risk. Preservation of olfaction may increase the postoperative quality of life. Objective assessment of olfaction may inform clinical decision-making and influence the selection of operative approaches for surgical resection. We reviewed all patients who underwent surgical resection for midline anterior skull base meningiomas from July 1, 2014, through December 31, 2017. Patient demographics, tumor size, operative approach, pre- and postoperative deficits, and Simpson grade were collected and analyzed. Postoperative olfaction was assessed by clinical evaluation as well as objective evaluation using the University of Pennsylvania Smell Identification Test (UPSIT). Twenty-eight patients (10 male, 18 female) were included with an average age of 53.8years (range 27-80years). Twenty-six patients underwent craniotomy for resection, while 2 patients had endoscopic approaches. Average tumor volume was 402.1cm3 (6.6-2507.7cm3). Preoperatively, five patients (17.8%) presented with olfactory impairment. Objectively, 50% of patients (14/28) consented and completed the UPSIT. The average postoperative UPSIT score was 25.8/40 (9/40-38/40). Two patients not identified on clinical assessment alone demonstrated postoperative olfactory deficit on UPSIT (2/14). There are limited published studies evaluating olfaction in patients who undergo skull-based approaches for anterior fossa meningiomas. Our series showed the highest olfaction preservation rate (87.5%) using a comprehensive strategy and multitude of surgical approaches based on the olfactory function and tumor characteristics.

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

Reconstruction of the skull base after resection of skull base meningiomas is of paramount importance. Here we describe a safe and effective method of skull base reconstruction using autologous free fat grafts. In this retrospective analysis of patients operated for skull base meningioma from 2007 to 2014. We analyzed the surgical technique, efficiency and safety as well as the graft-related complications. Autologous free fat grafts were used in 55 patients, including 39 patients with posterior fossa meningiomas related to the petrous bone and 16 patients with anterior fossa meningiomas related to the paranasal sinuses. Three patients experienced postoperative cerebrospinal fluid (CSF) leak and were managed with temporary continuous lumbar drainage. One patient developed pneumocephalus and required revision. The occurrence of CSF leak was related to aggressive resection with resulting large skull base defects, especially in anterior skull base meningiomas. There were no donor site-related complications. The use of autologous free fat grafts is an effective and safe technique for reconstructing skull base defects after microsurgical resection of skull base meningiomas.

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

Reconstruction of the skull base after resection of skull base meningiomas is of paramount importance. Here we describe a safe and effective method of skull base reconstruction using autologous free fat grafts.In this retrospective analysis of patients operated for skull base meningioma from 2007 to 2014. We analyzed the surgical technique, efficiency and safety as well as the graft-related complications.Autologous free fat grafts were used in 55 patients, including 39 patients with posterior fossa meningiomas related to the petrous bone and 16 patients with anterior fossa meningiomas related to the paranasal sinuses. Three patients experienced postoperative cerebrospinal fluid (CSF) leak and were managed with temporary continuous lumbar drainage. One patient developed pneumocephalus and required revision. The occurrence of CSF leak was related to aggressive resection with resulting large skull base defects, especially in anterior skull base meningiomas. There were no donor site–related complications.The use of autologous free fat grafts is an effective and safe technique for reconstructing skull base defects after microsurgical resection of skull base meningiomas.

Temporal-based pericranial flaps for orbitofrontal Dural repair: A technical note and Review of the literature

Abstract Introduction Pericranial flaps are widely used for dural repair as they are easily accessible and have a lower rate of infection than artificial grafts. Vascularized flaps increase the rate of successful dural closure and minimize the risk of cerebrospinal fluid leak and infection. However, regional access can be limited by the necessity of maintaining the vascularized pedicle. Classically, frontal-based vascularized flaps have been used for dural repair after orbitalfrontal approaches to large anterior fossa meningiomas. We present an alternative lateral temporal-based flap for dural repair in orbitalfrontal approaches. Surgical Technique & Methods Two cases are presented where a temporal-based flap was used. In the two cases presented, we found that temporal-based pericranial flaps can be harvested with preservation of blood supply and can achieve watertight dural closure. The surgical technique and relevant anatomy are described. Surgical results and clinic follow up are reported. Conclusions A temporal-based pericranial flap represents an alternative vascularized pedicle flap to the classic frontal-based pericranial flap used in orbitofrontal dural repair. In certain clinical settings, the temporal-based flap may be preferable.

Indicators of a Reduced Intercarotid Artery Distance in Patients Undergoing Endoscopic Transsphenoidal Surgery.

Objective To identify clinicopathologic factors associated with a reduced intercarotid distance (ICD) and subgroups at risk for internal carotid artery injury during transsphenoidal surgery. Design A retrospective case-control study. Setting This study was conducted at the McGill University Health Centre, a university-affiliated tertiary care center. Participants Patients with a sellar or parasellar tumor and nontumor controls were included in the study. Main Outcome Measures The smallest distance between the internal carotid arteries at the clival, cavernous, and paraclinoid segments on coronal magnetic resonance imaging was measured. Demographic profiles, cephalometric measurements, tumor dimensions, and sphenoid configuration were assessed as potential determinants of the ICD. Results A total of 212 cases and 34 controls were analyzed. Widening of the ICD at the three segments of the internal carotid arteries was found in patients with pituitary macroadenomas (p < 0.01). Patients with a growth hormone-secreting adenoma had a markedly reduced ICD at the clivus compared with controls (1.59 cm versus 1.77 cm; p = 0.02; 95% confidence interval [CI], 0.03-0.32). The paraclinoid ICD was reduced in patients with an anterior fossa meningioma (1.24 cm versus 1.33 cm; p = 0.04; 95% CI, 0.01-0.45). Conclusion Identifying clinicopathologic factors affecting the ICD can help surgeons recognize constraints to endoscopic access of the skull base and avoid inadvertent arterial injury.

Intraoperative Extracorporeal Irradiation for the Treatment of the Meningioma-Infiltrated Calvarium

Introduction: Because meningiomas often involve the adjacent calvarium, partial or complete removal of infiltrated bone is required to achieve a gross total, Simpson grade 1 resection.Reconstruction of the resulting bone defect is typically achieved with a non-native implant, which can often result in poor cosmesis, foreign body reaction, or infection.Extracorporeal irradiation and reimplantation of tumorous bone has been used for limb-sparing surgery with excellent results, but this treatment option is not routinely considered in meningioma surgery.We present a case of anterior fossa meningioma with tumorous overlying calvarium that was successfully managed with intraoperative extracorporeal irradiation and reimplantation.

Anterior Cranial Fossa Meningioma: Outcome of Surgery Using Different Surgical Approaches

Objective: To review patterns of clinical presentation, radiological features, and outcomes of surgical excision of anterior fossa meningioma.

Anterior Skull Base Rhabdoid Meningioma Masquerading as Esthesioneuroblastoma

Introduction: Radiographic diagnoses of high-grade meningiomas can be complicated by unusually aggressive anatomy. This is particularly true for lesions exhibiting expansile extracranial growth or cystic structures, findings that are often characteristic of rarer tumors. We report for the first time a giant anterior fossa meningioma exhibiting anatomy classically suggestive of esthesioneuroblastoma.

Expanded endonasal endoscopic resection of anterior fossa meningiomas: report of 13 cases and meta-analysis of the literature

Transnasal endoscopic (TNE) approaches have been proposed for the resection of anterior cranial base meningiomas. The purpose of this article was to evaluate the results of endoscopic resection of anterior cranial fossa meningiomas by reviewing available published data in addition to the authors' experience with 13 cases. The literature was searched via OVID to identify all available disaggregate data pertaining to anterior fossa meningiomas treated primarily by TNE. In addition, the authors reviewed the records of a personal series of 13 patients who underwent TNE removal of parasellar meningiomas through a pure TNE approach. Meta-analysis from studies included a total of 69 patients with adequate disaggregated data to summarize. Mean age (± SD) at surgery was 53.3 ± 13.0 years (range 27-80 years); 78% of the patients were women. Tumor size was skewed toward smaller lesions, with a mean volume of 24.4 ± 2.9 cm(3). Intraoperative impressions were of gross-total resection in 76% of cases. The most common complication reported was CSF leakage, occurring in 32% of the cases (22 of 69). The rate of CSF leakage was not affected by size (p = 0.52), location of tumor (p = 0.9), or age (p = 0.56). There was 1 death overall. The mean duration of follow-up was 21 ± 18 months. Transnasal endoscopic resection of anterior cranial base meningiomas is feasible in selected cases. Reported resection rates are adequate, although the follow-up in the reported series is too short (mean 21 months) to make definitive conclusions regarding the long-term effectiveness. Cerebrospinal fluid leakage is a common complication, although it appears not to be associated with additional morbidity except for the need for reoperation. Long-term results are necessary before considering TNE resection as a valid alternative, in selected cases, to the more established transcranial techniques.

Anton’s syndrome due to a giant anterior fossa meningioma. The problem of routine use of advanced diagnostic imaging in psychiatric care

We present a case of blindness and Anton's syndrome in a psychiatric patient with late diagnosis of a giant frontal meningioma. The criteria for advanced diagnostic imaging in the psychiatric population are discussed. We conclude that MR or CT scan is indicated in psychiatric in-patients who fail to improve with standard psychiatric treatment. This strategy should be submitted to a cost-benefit analysis.

Selective angiography of the external and internal carotid arteries in the diagnosis of supra-tentorial meningiomas

From a study of 85 supratentorial meningiomas, the Authors draw the following conclusions: 1. Angiography of the internal carotid is the examination of choice in anterior fossa meningiomas supplied by branches of the ophthalmic artery. — 2. Angiography of the external carotid is very valuable in meningiomas of the convexity. — 3. An area of newly-formed pathological vessels on the external carotid angiography is indicative, however not pathognomonic, of a meningioma.