Anterior Skull Base Meningiomas Research Articles

5-ALA Endoscope-Assisted Surgery of the Anterior Skull Base

Objective: In skull base surgery endoscopic techniques gain increasing importance. In gliomas 5-ALA fluorescence-guided surgery (FGS) could increase radicality and improve PFS. We proposed to establish the proof of principle to resect anterior skull meningiomas with help of a 5-ALA endoscope (5-ALA eFGS). Material and Methods: Two patients with anterior skull base meningiomas were operated using a special endoscope equipped for 5-ALA FGS. Results: Patient number 1 was operated by a combined transnasalendoscopic and transcranial approach. Patient number 2 was operated via an endoscope-assisted transeyebrow subfrontal approach. In both the patients fluorescing tumor was well visualized by the endoscope and it helped to detect a residual tumor at the end of surgery. Conclusion: We established the proof of principle to use a 5-ALA endoscope as an additional tool in anterior skull base surgery.

Endonasal Endoscopic Approaches for Anterior Skull Base Meningiomas: Evaluation of Potential Benefits on Outcome Compared with Transcranial Approaches

Endonasal Endoscopic Approaches for Anterior Skull Base Meningiomas: Evaluation of Potential Benefits on Outcome Compared with Transcranial Approaches

Visual outcome after fractionated stereotactic radiation therapy of benign anterior skull base tumors.

To determine visual outcome including the occurrence of radiation induced optic neuropathy (RION) as well as tumor control after fractionated stereotactic radiation therapy (FSRT) of benign anterior skull base meningiomas or pituitary adenomas. Thirty-nine patients treated with FSRT for anterior skull base meningiomas and 55 patients treated with FSRT for pituitary adenomas between January 1999 and December 2009 with at least 2 years follow-up were included. Patients were followed up prospectively with magnetic resonance imaging scans, visual acuity and visual field examinations. RION was found in four (10 %) patients with anterior skull base meningiomas and seven patients (13 %) with pituitary adenomas. The five-year actuarial freedom from 25 % RION visual field loss was 94 % following FSRT. Actuarial 2-, 5- and 10-year tumor control rates were 100, 88.4 and 64.5 % for anterior skull base meningiomas and 100, 98.2 and 94.9 % for pituitary adenomas, respectively. Patients with an impaired visual field function pre-FSRT were more likely to experience worsened function (p = 0.016). We found that RION, was a relatively uncommon event, in a large prospective cohort of patients that were systematically monitored following FSRT of benign anterior skull base tumors. Long term tumor control was favorable, especially for pituitary adenomas.

Preoperative ethmoid artery ligation facilitates resection of large sub-frontal meningiomas

Optimal vascular control during neurosurgical resection of large sub-frontal meningioma is hindered by limited early access to the ethmoidal arteries. Pre-operative ligation of the ethmoidal arteries 1) induces tumor necrosis simplifying resection and 2) minimizes blood loss and operative time. Early arterial ligation is an advantage of endoscopic approaches to transnasal resection of anterior skull base meningiomas that is not appreciated in open approaches with larger meningioma. Here we present a case of a colossal meningioma where minimally invasive pre-operative ligation of ethmoidal arteries prior to a traditional open surgical approach allowed for improved vascular control and decreased surgical time.

Surgical management of midline anterior skull base meningiomas: experience of 30 cases.

Midline anterior skull base meningiomas include olfactory groove meningiomas (OGMs), Tuberculum Sellae meningiomas (TSMs), and planum sphenoidale meningiomas (PSMs). The main surgical challenge in treating these lesions is to excise the tumor totally without causing mortality or morbidity. Studying the clinical patterns and the surgical outcomes of these lesions. Thirty cases of midline anterior skull base lesions were included in our study. Patients were operated upon by four routes: (i) unilateral subfrontal, (ii) bilateral subfrontal, (iii) frontotemporal approach, and (iv) bifrontal basal interhemispheric. Extent of resection was classified according to the Simpson grading system. The functional outcome of the patients was assessed by comparing the preoperative and the postoperative neurological examination, as well as the Karnofsky performance scale. We had 14 OGMs (46.7%), 9 TSMs (30%), and 7 PSMs (23.3%). The most commonly utilized approach was the subfrontal approach (unilateral or bilateral) in 80% of the cases, followed by the pterional approach in 16.6% of the cases. Total removal was achieved in 86.7% of the cases; subtotal excision was achieved in 13.3% of the cases. 41.2% of our cases showed postoperative clinical improvement. We had two mortalities in our study, representing 6.7%. We did not detect any tumor recurrences in our follow up. The median preoperative Karnofsky scale was 85, while the median postoperative Karnofsky scale was 90. Midline anterior skull base lesions are becoming amenable for total surgical excision with minimal morbidities and mortalities. Most preferred surgical routes are the subfrontal and the pterional approaches.

The lion's mane sign: surgical results using the bilateral fronto-orbito-nasal approach in large and giant anterior skull base meningiomas

Concerns about extreme peritumoral edema and its ensuing surgical and perioperative complications led the authors to use the bilateral fronto-orbito-nasal approach to remove midline anterior skull base meningiomas that were larger than 4 cm. The authors hypothesize that extreme vasogenic edema exemplified by finger-like hyperintensities extending into the bifrontal white matter and external capsule and/or the extreme capsule, coined the lion's mane sign (LMS), would help identify patients with a challenging postoperative course. They hypothesize that the LMS would better predict symptomatic postoperative cerebral edema than the edema index (EI). This is an observational case series of 9 patients. The authors noted the grade, pathology, tumor volume, EI, and the presence or absence of the LMS in all tumors. They used the intensive unit care (ICU) length of stay as a nonspecific measure reflecting postoperative symptomatic cerebral edema. Comparisons of edema-related postoperative complications and the EI were made between patients with and without an LMS. Bifrontal hyperintensities, extending into at least three-eighths of the length of the external capsules on T2-weighted MRI, seen in 4 of 9 patients, portended a longer postoperative ICU stay. The presence of an LMS better predicted postoperative complications related to cerebral edema than tumor grade, pathology, volume, or EI. The LMS predicts an increased duration of stay in the ICU after a bilateral fronto-orbito-nasal approach for resection of large and giant anterior skull base meningiomas. Furthermore, the LMS better predicted increased length of stay in the ICU than did the EI.

Extracranial ligation of ethmoidal arteries before resection of giant olfactory groove or planum sphenoidale meningiomas: 3 illustrative cases with a review of the literature on surgical techniques

There are several surgical techniques for reducing blood loss-open surgical and endoscopic-prior to resection of giant anterior skull base meningiomas, especially when preoperative embolization is risky or not technically feasible. The authors present examples of an institutional experience using surgical ligation of the anterior and posterior ethmoidal arteries producing persistent tumor blush in partially embolized tumors. The authors identified 12 patients who underwent extracranial surgical ligation of ethmoidal arteries through either a transcaruncular or a Lynch approach. Of these, 3 patients had giant olfactory groove or planum sphenoidale meningiomas. After approval from the institution privacy officer, the authors studied the medical records and imaging data of these 3 patients, with special attention to surgical technique and outcome. The variations of ethmoidal artery foramina pertaining to this surgical approach were studied using preserved human skulls from the Hamann-Todd Osteological Collection at the Museum of Natural History, Cleveland, Ohio. The extracranial ligation was performed successfully for control of the ethmoidal arteries prior to resection of hypervascular giant anterior skull base meningiomas. The surgical anatomy and landmarks for ethmoidal arteries were reviewed in anthropology specimens and available literature with reference to described surgical techniques. Extracranial surgical ligation of anterior, and often posterior, ethmoidal arteries prior to resection of large olfactory groove or planum sphenoidale meningiomas provides a safe and feasible option for control of these vessels prior to either open or endoscopic resection of nonembolized or partially embolized tumors.

Early experience of resection of meningiomas in anterior skull base with intra-extracranial extension via a pure endoscopic endonasal approach

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.

Utility of a rotation–suction microdebrider for tumor removal in endoscopic endonasal skull base surgery

The microdebrider is a common tool used in endoscopic sinus surgery for removing polypoid and sinonasal tissue. It uses rotating blades and an integrated suction device for controlled removal of tissue under video–endoscopic visualization. To our knowledge, the application of the microdebrider for endoscopic removal of skull base tumors has not been reported. This study aimed to investigate the utility of the rotation–suction microdebrider as a tool for endoscopic endonasal removal of solid and fibrous skull base tumors. Thirty-two patients underwent endoscopic endonasal skull base surgery where the rotation–suction microdebrider was used as the primary tool for tumor removal and debulking. Pathologies included a variety of anterior skull base meningiomas, sinonasal skull base malignancies, juvenile nasopharyngeal angiofibromas, schwannomas, and other skull base lesions. Gross total and near total removal was achieved in 87.5% (28/32) of patients, and subtotal removal was performed in 12.5% (4/32) of patients. The microdebrider allowed efficient debulking and removal of solid and fibrous tumors, such as meningiomas, that were not responsive to standard ultrasonic aspiration. There were no complications of orbital or neurovascular injury, or thermal injury to the nostril. The rotation–suction microdebrider is a useful tool for endoscopic endonasal removal of skull base tumors. This is particularly useful for solid and fibrous tumors that are not responsive to standard ultrasonic aspiration. For intracranial tumors, it is critical to remain inside the tumor capsule during debulking so as to avoid injury to the surrounding neurovascular structures.

Endoscopia endonasal de base de cráneo

The endoscopic endonasal techniques used in skull base surgery have evolved greatly in recent years. Our study objective was to perform a qualitative systematic review of the likewise systematic reviews in published English language literature, to examine the evidence and conclusions reached in these studies comparing transcranial and endoscopic approaches in skull base surgery. We searched the references on the MEDLINE and EMBASE electronic databases selecting the systematic reviews, meta-analyses and evidence based medicine reviews on skull based pathologies published from January 2000 until January 2013. We focused on endoscopic impact and on microsurgical and endoscopic technique comparisons. Full endoscopic endonasal approaches achieved gross total removal rates of craniopharyngiomas and chordomas higher than those for transcranial approaches. In anterior skull base meningiomas, complete resections were more frequently achieved after transcranial approaches, with a trend in favour of endoscopy with respect to visual prognosis. Endoscopic endonasal approaches minimised the postoperative complications after the treatment of cerebrospinal fluid (CSF) leaks, encephaloceles, meningoceles, craniopharyngiomas and chordomas, with the exception of postoperative CSF leaks. Randomized multicenter studies are necessary to resolve the controversy over endoscopic and microsurgical approaches in skull base surgery.

Intraoperative ultrasound assistance in resection of intracranial meningiomas.

Intracranial meningiomas, especially those located at anterior and middle skull base, are difficult to be completely resected due to their complicated anatomy structures and adjacent vessels. It's essential to locate the tumor and its vessels precisely during operation to reduce the risk of neurological deficits. The purpose of this study was to evaluate intraoperative ultrasonography in displaying intracranial meningioma and its surrounding arteries, and evaluate its potential to improve surgical precision and minimize surgical trauma. Between December 2011 and January 2013, 20 patients with anterior and middle skull base meningioma underwent surgery with the assistance of intraoperative ultrasonography in the Neurosurgery Department of Shanghai Huashan Hospital. There were 7 male and 13 female patients, aged from 31 to 66 years old. Their sonographic features were analyzed and the advantages of intraoperative ultrasonography were discussed. The border of the meningioma and its adjacent vessels could be exhibited on intraoperative ultrasonography. The sonographic visualization allowed the neurosurgeon to choose an appropriate approach before the operation. In addition, intraoperative ultrasonography could inform neurosurgeons about the location of the tumor, its relation to the surrounding arteries during the operation, thus these essential arteries could be protected carefully. Intraoperative ultrasonography is a useful intraoperative technique. When appropriately applied to assist surgical procedures for intracranial meningioma, it could offer very important intraoperative information (such as the tumor supplying vessels) that helps to improve surgical resection and therefore might reduce the postoperative morbidity.

Expanded endonasal approach to skull base meningiomas

Expanded endonasal endoscopic approach is an alternative technique for management of meningiomas of the anterior skull base, allowing complete resection with an acceptable morbidity rate.We report the first three cases of anterior skull base meningiomas managed by this technique […]. Expanded endonasal approach to skull base meningiomas

Hypopituitarism after fractionated stereotactic radiation therapy of anterior skull base meningiomas is caused by mass effects, not radiation

Hypopituitarism after fractionated stereotactic radiation therapy of anterior skull base meningiomas is caused by mass effects, not radiation

Institutional Review and Identification of Indications for Endoscopic Expanded Endonasal versus Craniotomy Approach to Anterior Skull Base Meningiomas

Institutional Review and Identification of Indications for Endoscopic Expanded Endonasal versus Craniotomy Approach to Anterior Skull Base Meningiomas

Surgical management of tuberculum sellae and planum sphenoidale meningiomas

Abstract Introduction: Tuberculum sellae and planum sfenoidale meningiomas represent 5% to 10% of intracranial meningiomas and represent a subgroup of anterior skull base meningiomas. Approximately two thirds of patients complain of failing vision in one eye as the first symptom, and monocular blindness may be present in half of patients before surgery. Due to the constant antomical relationship of these tumors with the optic nerves there is a classic presentation of these tumors represented by the chiasmal syndrome. Material and methods: In this study, we have retrospectively analyzed 18 cases consecutively operated between 2006 and 2012 at the Targu Mures Neurosurgery Department. Considering the length of the visual disturbances we have divided the study group in two categories: early decompression with visual distubances expressed within at most 12 months prior to surgery, and late decompression with visual disturbances of more than 1 year. Surgical technique: Sugical approach has been performed on the side with the most visual deficit, and if visual deterioration was found to be approximative on both sides we chose the right side for surgical approach. In all the patients, we have performed a fronto-pterional craniotomy. In all the cases we chose a subfrontal approach. Tumor has been further resected using standard microsurgical techniques, total tumoral resection being the preoperative goal in all surgical interventions Results: Out of the 18 cases operated, 13 cases were of tuberculum sellae meningiomas, while 5 cases were of planum sphenoidale meningiomas. All patients in the early decompression group (9 cases) have presented visual improvement, whilst of the late decompression group 5 cases (55,5%) presented constant visual deficit, 2 cases (22,25%) presented visual improvement and 2 cases (22,25%) presented a decrease of the visual deficit. The visual disturbances have improved in 11 cases (61.1%), in 5 cases (27,7%) the visual deficit has remained constant, and in 2 cases (11,2%) the visual deficit has worsened postoperatively. Conclusions: We consider that the optimal approach should be based on tumor anatomy and surgeon experience and from this point of view frontolateral and pterional approaches provide remarkable improvement compared to the bifrontal approach. Regardless of the selected surgical approach it is essential to avoid injury to the blood supply of the optic apparatus.Endoscopy will have a role in skull base surgery with

Pneumosinus dilatans in anterior skull base meningiomas

Skull base meningiomas are often missed on non-contrast CT or MR examinations due to their close proximity to bone and low lesion to brain contrast. The purpose of this study is to illustrate that pneumosinus dilatans can be an indicator of anterior skull base meningiomas. A retrospective search of the radiology information system and picture archiving and computing system database was performed. Search terms were "meningioma" in association with "pneumosinus dilatans." Medical records and imaging studies were reviewed independently by two experienced neuroradiologists and were read in consensus. We recorded the patient age at the time of discovery of the meningioma, main presenting symptom(s), location of the tumor, and imaging characteristics. We also performed a comparative literature search for pneumosinus dilatans and its association with meningiomas. Ten patients (six women; four men) were identified in whom a meningioma of the anterior skull base was associated with a pneumosinus dilatans. Three patients had multiple meningiomas, so a total of 14 intracranial tumors were identified. Mean age at discovery was 59 years with an age range of ± 20years. All meningiomas were diagnosed by MRI and/or CT. Pneumosinus dilatans can be a helpful sign to indicate the presence of a meningioma of the anterior skull base.

Endoscopic Endonasal Resection of Anterior Skull Base Meningiomas and Mucosa: Implications for Resection, Reconstruction, and Recurrence

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.

Treatment outcomes after surgical resection of midline anterior skull base meningiomas at a single center

Meningiomas of the midline anterior skull base (ASB) typically grow around the optic chiasm. These tumors can displace or adhere to the optic apparatus, resulting in visual abnormalities. For this reason, in most studies of surgically resected meningiomas, only surgical and visual outcomes have been evaluated. However, in this study, we assessed overall clinical outcomes and the effects of different surgical approaches on outcomes. Clinical data for 126 patients who were treated surgically for midline ASB meningiomas between 1994 and 2009 were collected and reviewed retrospectively. The mean follow-up duration was 39months (range: 0.5–146months). Most procedures were performed via a pterional approach and did not require an aggressive skull base approach. Clinical outcomes were evaluated using our own criteria, and potential predictive factors for visual and clinical outcomes were tested statistically. The tumor control rate was 83% (105/126). Immediate postoperative visual status and optic canal involvement were correlated with visual outcome. Of the patients who ultimately had improved visual status, only six were originally categorized as having severe visual impairment (all were only able to count fingers). In terms of clinical outcome, 41 patients were classified as “excellent”, 32 as “good”, 29 as “fair”, and 20 as “poor”. A symptom duration of less than six months, less severe preoperative visual symptoms of the affected eye, and the extent of resection were all correlated with improved clinical outcome. Involvement of the optic canal, adherence of the tumor to the optic nerve, and major arterial encasement by the tumor were associated with poor clinical outcome. We recommend that in patients with unilateral severe visual impairment, the focus should be on improving visual function in the contralateral eye. Preoperative and postoperative evaluation of several variables allows for the prediction of clinical and visual outcomes.

Different Surgical Approaches in Anterior Skull Base Meningiomas: Our Experience of a Surgical Series and Literature Review

Objective: To this day anterior skull base meningiomas still remain a surgical challenge. In our work, we review a series of anterior base meningiomas operated on from 1990 to 2010 and compare our data with papers in the literature.

Visual Function after Bony Decompression of Meningiomas Invading the Optic Canal: The Value of Anterior Clinoidectomy

Objective: Anterior skull base meningiomas frequently extend into the optic canal and cause progressive visual impairment. Surgical decompression of the optic nerve is the only option to preserve visual function.