Endoscopic Endonasal Technique Research Articles

Early Predictors of Remission in Acromegaly Patients after Pure Endoscopic Endonasal Transsphenoidal Surgery

Abstract Objective Surgery is the first-line treatment in acromegaly but it takes months to confirm remission. It is crucial to determine remission early in order to inform the patient and plan further treatment options. We aimed to evaluate the predictors of remission at the early phase after endoscopic endonasal pituitary surgery in acromegaly patients. Methods Fifty-four growth hormone (GH)-adenoma patients operated via pure endoscopic endonasal approach were analyzed in this observational study. We compared the basic clinical, radiological characteristics, and the preoperative and postoperative hormone levels in terms of remission according to current guidelines. Results The surgical remission rate was 61.1%. When the patients were compared according to surgical remission, the age, gender, and immunohistochemical granulation type were found to be nonsignificant, while diabetes mellitus was more common (55.6 vs. 44.4%). The preoperative tumor volume (1.2 ± 0.9 vs. 4.1 ± 4.2 cm3) and postoperative GH and insulin-like growth factor-1 (IGF-1) levels were higher in the nonremission group (p < 0.05). We defined a number of cut-off values of both GH and IGF-1 levels to predict remission at the postoperative phase. Age standardized regression analyses showed that postoperative day 1 (POD-1) GH levels (odds ratio [OR]: 8.9; 95% confidence interval [CI]: 1.99–40.0, p = 0.004) and tumor volume (OR: 3.14; 95% CI: 1.09–9.0, p = 0.034) were found to be significant independent predictors for remission. Conclusion We demonstrated that tumor volume and POD-1 GH levels are independent predictors of remission in acromegaly patients operated via the pure endoscopic endonasal technique and may be used as an early marker of remission, and this may lead to taking adjuvant medical therapies early into account to improve prognosis.

Inverted papilloma of the nose and paranasal sinuses : Diagnosis, treatment, and malignant transformation

Inverted papilloma (IP) are benign tumors that show alocally aggressive behavior, ahigh rate of recurrence, and apotential for malignant transformation. Specific radiological signs such as hyperostosis at the origin of the IP and convoluted cerebriform patterns, as well as the typical endoscopic aspect, can lead to diagnosis and enable preoperative planning of surgical access and the extent of surgery. Endonasal endoscopic techniques are considered the gold standard and the introduction of extended surgical techniques such as the prelacrimal approach, frontal drillout, or orbital transposition facilitate complete subperiosteal resection with preservation of important physiological structures. There is arisk of synchronous and metachronous squamous cell carcinomas (IP-SCC). Research focuses on radiological criteria to differentiate benign IP from IP-SCC, genetic and epigenetic factors in the process of malignant transformation, and estimation of the risk of IP progressing to IP-SCC.

Endoscopic endonasal transclival clipping of a cerebellar arteriovenous malformation feeding vessel and associated aneurysm; a 2D operative video

Positioned along the ventral surface of the pons, proximal superior cerebellar artery (SCA) aneurysms account for only 1.7% of all intracranial aneurysms [1]. Unlike more commonly encountered basilar artery aneurysms, patients often experience good outcomes when treated via endovascular coiling or surgical clipping [1,2]. These lesions frequently have a lateral projection and paucity of perforator arteries [2]. With further development of endoscopic endonasal techniques, access to this region is possible via a direct frontal exposure to the ventral brainstem, basilar artery and branching vessels. To date, there are only a limited number of reports describing an endoscopic endonasal transclival (EETC) approach for surgical clipping [3–5]. In this operative video, we detail the surgical clipping of a cerebellar arteriovenous malformation feeding vessel and an associated aneurysm using the EETC approach in a 59-year-old woman who presented with sudden onset of a severe headache. The feeding vessel and aneurysm’s midline location, just below the take-off of the SCA made it a good candidate for this surgery. Major steps included in this video include 1) transsphenoidal exposure of and subsequent drilling of the clivus, 2) dural opening into the pre-pontine cistern and dissection of the aneurysm, 3) clipping of the aneurysm, and 4) multi-layered closure of the skull base defect. Overall, the patient tolerated the procedure well and was found to have no residual filling of the aneurysm or the AVM feeding vessel at 2-year follow-up. EETC is a viable surgical option for the treatment of aneurysm located along the midline of the pre-pontine cistern.

Clival Chordomas in the Endoscopic Endonasal Era: Comparison With Management With Open Skull Base Approaches.

The most significant paradigm shift in surgical management of skull base chordomas has been the adoption of the endoscopic endonasal approach, but the impact on patient outcomes compared with open skull base approaches remains unclear. To compare a large series of patients treated by a single surgeon using primarily endoscopic endonasal approaches with previously published outcomes by the same surgeon using open skull base approaches. Between 2006 and 2020, 68 patients with skull base chordoma underwent resection using primarily endoscopic endonasal approaches. Outcomes and complications were compared with previously published results of resection of chordomas from 1991 to 2005 using open skull base approaches. Compared with the prior cohort, the current principally endoscopic cohort demonstrated similar rates of OS ( P = .86) and progression-free survival ( P = .56), but patients undergoing first-time resection had significantly higher rates of radical resection (82.9% compared with 64.3%, P = .05) and required fewer staged surgeries (9.8% compared with 33.3%, P = .01). There was no difference in survival rates for patients treated in the current era, primarily using endoscopic endonasal techniques, compared with previously published results using open skull-base approaches by the same surgeon. Although use of endoscopic endonasal approach resulted in higher rates of radical resection, patients undergoing first-time resection and fewer staged surgeries were required.

The Evolution of Endoscopic Endonasal Approach for Olfactory Groove Meningiomas.

There is controversy over the choice of optimal approach for olfactory groove meningiomas (OGM). The endoscopic endonasal approach (EEA) is one of the most recently described corridors, which provides direct access to the tumor base. To detail the evolution of the endoscopic endonasal technique over the past 2 decades and demonstrate the impact of this evolution on patient outcomes. This is a retrospective study based on a prospectively maintained database of consecutive cases of OGM operated on at our institution via EEA. For analysis, the whole cohort has been divided into 3 equal "eras" according to the time period during which the surgery happened, creating early, middle, and contemporary groups. Seventy-five patients were included, 25 in each group. The rate of postoperative cerebrospinal fluid leak significantly decreased over time (28%, 32%, and 8% in the early, middle, and contemporary groups, respectively, P = .020). The rate of postoperative encephalomalacia was significantly lower in more recent groups (24%, 16%, and 0% in the early, middle, and contemporary groups, respectively, P = .029), as was the time to resolution of postoperative brain edema (103.9 months, 87.3 months, and 16.8 months in the early, middle, and contemporary groups, respectively, P = .020). The endoscopic endonasal approach for OGM significantly evolved over time, achieving lower cerebrospinal fluid leak rates while providing a high rate of Simpson grade 1 resection. Technical improvements minimized the frontal lobe impact. Current data support EEA as a safe and effective corridor to treat OGM.

Endoscopic endonasal treatment of craniopharyngiomas: current management strategies and future perspectives.

Craniopharyngiomas are locally aggressive disembryogenetic tumors presenting mostly in childhood and late adulthood. They are often burdened by an unfavorable clinical course due to close relationships with nearby critical neurovascular structures and high risk of recurrences. The aim of our paper is to provide a systematic review of the literature regarding current strategies and future perspectives for the treatment of craniopharyngiomas, focusing on the role of endoscopic endonasal surgery. A comprehensive literature search of three databases (PubMed, Ovid Medline, and Ovid Embase) has been conducted to identify papers addressing the management strategies in adult and pediatric craniopharyngioma patients. Twenty-two articles have been included, providing data for 560 adult and 215 pediatric patients. Mean follow-up was 40.29 months for the adult and 58.05 months for pediatric population. GTR rate was 60.97% and 82.52% in adult and pediatric patients, respectively. Adjuvant radiotherapy was delivered in 20.99% of adult and 8.25% of pediatric cases; 89% of adult patients and 94.11% of pediatric patients receiving radiotherapy had previously undergone NTR, STR or partial resection. The recurrence rate was 19.32% and 18.61% for adult and pediatric population, respectively. Recurrences occurred mostly in patients receiving incomplete resection without adjuvant radiotherapy (72.87% in adults and 51.28% in children); 86.69% and 87.12% of adult and pediatric patients reported improvement of their previous ophthalmologic deficit; 40% of the adult population and 41.86%% of pediatric patients worsened or developed endocrinological disturbances. CSF leak rate was 16.4% in adults and 13.95%% in children. Modern policy of craniopharyngioma management is represented by the combination of a "maximum safe" allowed surgical removal plus radiotherapy. In this scenario, the endoscopic endonasal technique proved to be a valid approach for removing these lesions, providing satisfactory outcomes with lower morbidity.

Analyzing giant pituitary adenomas: An 8-year review (2012–2020) at a reference center in Brazil

PurposeThis study aimed to review the cases of giant adenomas that were operated on from 2012 to 2020 and to analyze the epidemiological profile, complications, and resection rates using the transseptal/transnasal endoscopy technique. We also compared the results with data from revised literature. MethodsThis is an observational, retrospective study includes a review of the medical records of 26 patients diagnosed with giant adenomas (diameter > 4 cm or volume >10 cm3) who underwent 28 surgical procedures. ResultsOf the 57 patients operated for pituitary adenoma, 26 (50.8%) had giant adenomas. The mean volume was 17.28 cm3 (95% confidence interval [CI], 8.3359–26.2241). Moreover, 64.28% of the patients were graded Knosp 3 (p < 0.0001). Most cases were of nonsecretory adenomas (88.46%). Visual impairment was present in 89.2% of the patients and hormonal deficit and headache affected 53.5% of them. The visual impairment improved in 60% of the patients. The most common surgical complication was cerebrospinal fluid fistula (10.71%). Tumor resection > 90% was achieved in 53.56% of the cases, and the mean resection rate was 78.36% (95% CI, 71.316–87.956). ConclusionsThe endoscopic endonasal technique is a good treatment option for giant adenomas, showing satisfactory optic apparatus decompression rates and a low incidence of complications when performed by surgeons with expertise in this approach.

Endoscopic endonasal technique in the treatment of malignant nasal cavity tumors extending to the skull base. Assessment of short-term results

<h3></h3> Опухоли полости носа, распространяющиеся на основание черепа, встречаются довольно редко, на их долю приходится от 3 до 5% злокачественных новообразований головы и шеи. Многие из них, ранее требующие травматичной краниофациальной резекции, теперь можно удалить через эндоскопический эндоназальный доступ. <h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Улучшение качества лечения пациентов с опухолями полости носа, распространяющимися на основание черепа. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> В исследование вошло 13 пациентов, оперированных по поводу злокачественных новообразований полости носа, распространяющихся на основание черепа, с использованием эндоскопического эндоназального доступа либо с эндоскопической эндоназальной ассистенции. <h3>РЕЗУЛЬТАТЫ И ОБСУЖДЕНИЕ</h3> Среди 13 пациентов с распространенными опухолями полости носа было 8 женщин и 5 мужчин в возрасте от 33 до 72 лет. В трех случаях диагностирована хондросаркома G1, в 1 — хондросаркома G2, в 2 — мукозальная меланома, в 2 — нейроэндокринная опухоль G1, в 1 — нейроэндокринная опухоль G 2-3, в 1 — нейробластома G3, в 2 — аденокистозный рак, в 1 — плоскоклеточный рак. Тотальное удаление опухоли было выполнено в 10 случаях, субтотальное — в 2 и частичное — в 1. <h3>ЗАКЛЮЧЕНИЕ</h3> Ближайшие результаты использования эндоскопической эндоназальной методики позволяют предположить, что данный способ улучшит качество лечения пациентов с злокачественными опухолями носа, распространяющимися на основание черепа. Однако оценка долгосрочных результатов лечения пациентов с такими опухолями требует дальнейшего изучения.

Surgical repair of choanal atresia: Retropalatal endoscopic versus endonasal endoscopic technique

Surgical repair of choanal atresia: Retropalatal endoscopic versus endonasal endoscopic technique

In Reply to the Letter to the Editor Regarding “Cytotoxicity and Effect of Topical Application of Tranexamic Acid on Human Fibroblast in Spine Surgery”

The literature on the use of intraoperative computed tomography (iCT) is sparse. We provide our experience of the usefulness of iCT in extent of resection in large and giant pituitary adenomas.A retrospective review was performed of cases using the endonasal endoscopic technique in which iCT was used. Demographic factors, number of scans, and impact on the extent of resection are reported, with visual acuity and field changes. Tumors were graded according to the Hardy classification. Patients with cavernous sinus invasion were excluded.All patients received a perioperative computed tomography scan with our iCT scanner. Thirty patients are reported, including 14 large and 16 giant pituitary adenomas, including 14 nonfunctional and 16 growth hormone–secreting tumors. The overall gross total resection (GTR), near-total resection, and subtotal resection rates were 83.3%, 16.7%, and 3.3%, respectively. iCT scanning detected residual in 13 of 30 patients, including 4 with 14 large (29%) and 9 with 16 (56.3%) giant adenomas promoting further surgery. iCT use improved GTR from 43.8% to 81.3% in giant adenomas and from 71% to 86% in large adenomas. Of the 13 patients in whom iCT detected residual disease, none required >2 iCT scans. No intraoperative complications were observed.iCT can improve extent of resection in large and giant pituitary adenomas and facilitate maximum safe resection such as GTR or near-total resection in patients where such should be attempted. iCT use may reduce iatrogenic complications and has select financial benefits in our patients' socioeconomic demographics. However, further prospective controlled studies are required to affirm our conclusions.

Usefulness of Intraoperative Computed Tomography on Extent of Resection of Large and Giant Pituitary Adenomas. Experience from a Developing Country

The literature on the use of intraoperative computed tomography (iCT) is sparse. We provide our experience of the usefulness of iCT in extent of resection in large and giant pituitary adenomas. A retrospective review was performed of cases using the endonasal endoscopic technique in which iCT was used. Demographic factors, number of scans, and impact on the extent of resection are reported, with visual acuity and field changes. Tumors were graded according to the Hardy classification. Patients with cavernous sinus invasion were excluded. All patients received a perioperative computed tomography scan with our iCT scanner. Thirty patients are reported, including 14 large and 16 giant pituitary adenomas, including 14 nonfunctional and 16 growth hormone-secreting tumors. The overall gross total resection (GTR), near-total resection, and subtotal resection rates were 83.3%, 16.7%, and 3.3%, respectively. iCT scanning detected residual in 13 of 30 patients, including 4 with 14 large (29%) and 9 with 16 (56.3%) giant adenomas promoting further surgery. iCT use improved GTR from 43.8% to 81.3% in giant adenomas and from 71% to 86% in large adenomas. Of the 13 patients in whom iCT detected residual disease, none required >2 iCT scans. No intraoperative complications were observed. iCT can improve extent of resection in large and giant pituitary adenomas and facilitate maximum safe resection such as GTR or near-total resection in patients where such should be attempted. iCT use may reduce iatrogenic complications and has select financial benefits in our patients' socioeconomic demographics. However, further prospective controlled studies are required to affirm our conclusions.

Anterior Skull Base Tumors and Surgery

Anterior skull base surgery requires intimate knowledge of a highly complex anatomic region containing critical neurovascular structures. A wide array of pathologies can occur along the anterior cranial base, including meningiomas, esthesioneuroblastomas, pituitary adenomas, craniopharyngiomas, chondrosarcomas, and chordomas. Advancements in endoscopic sinus surgery have allowed many of these tumors to be effectively treated via an endoscopic endonasal technique. This approach obviates the need for large incisions causing cosmetic deformity, improves magnification of the surgical field, and offers a direct path to lesions thus avoiding retraction of structures such as the brain and nerves. Surgeons must understand the limitations of endoscopic techniques and consider open or combined open and endoscopic approaches when appropriate. Reconstructive anterior skull base techniques vary depending on the size and location of defects, along with factors such as intracranial pressure and patient co-morbidities. Large skull base defects require multilayer reconstruction that include a watertight primary dural repair with either synthetic or autologous tissue, followed by local vascularized tissue flaps. This review contains 8 figures, 2 videos, 4 tables and 33 references Key words: Anterior skull base, meningioma, esthesioneuroblastoma, chordoma, pituitary, CSF leak, nasosptal flap, dural repair, expanded endonasal approaches, endoscopic surgery

Endonasal Endoscopic and Hybrid Surgery Techniques for Blunt Trauma Fractures of the Skull Base With Cerebrospinal Fluid Leaks.

Cerebrospinal fluid (CSF) leakage caused by skull base fracture represents high risks of bacterial meningitis, and a rate of mortality of 8.9%. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high rates of success. The aim of this study is to describe our technique for management of skull base CSF leaks secondary to craniofacial trauma based on the anatomic location of the leak. This is a retrospective case series of 17 patients with diagnosis of craniofacial trauma, surgically treated with sole endonasal endoscopic and combined endonasal/transcranial approaches with diagnosis of CSF leak secondary to skull base fractures. Seventeen patients met inclusion criteria for this study. Mean age was 46 years old. Most common etiology was motor vehicle. Early surgery was performed in 8 patients, and late surgery in 9 patients. The most common site of CSF leak was at ethmoid cells or at the fronto-ethmoid junction in 9 patients. Thirteen patients (76.4%) were treated only with endonasal endoscopic technique, and 4 (23.5%) with hybrid surgery, combining endonasal endoscopic and cranial bicoronal approaches with nasal and pericranial vascularized flaps, and nasal mucosal free flaps. Mean hospital stay was 23.7 days.The mean follow-up time was 25.6 months. When surgical reconstruction is indicated for CSF leaks secondary to skull base fractures, endonasal endoscopic techniques should be part of the surgical management either as a sole procedure, or in combination with classical transcranial approaches with high rates of success and low morbidity.

Petrosal Approach for Giant Retrochiasmatic Craniopharyngioma: 2-Dimensional Operative Video.

Microsurgical resection of craniopharyngiomas poses significant challenges, which are amplified with tumors in the retrochiasmatic location and larger size. Traditional pterional trans-sylvian, subfrontal translamia terminalis, or interhemispheric approaches provide narrow surgical corridors with obstructed visualization of the tumor by the prefixed chiasm and slit optic carotid window.1-5 The superior extension of the tumor compressing the hypothalamus and third ventricle are likewise inaccessible. Dissection through these approaches requires crossing and manipulation of the already compromised optic apparatus with surgical instruments. Finally, the basilar artery and its perforating branches are often adherent to the posterior aspect of the tumor, and are invisible. Endonasal endoscopic techniques have been utilized as a surgical approach that accesses the tumor without crossing the optic apparatus; however, these approaches have a significant risk of cerebrospinal fluid leakage and require dissection of the basilar artery and hypothalamus from long distances with lengthy instruments.6-9 Frequently, the surgeon achieves only partial removal. The petrosal approach is ideal for tumors in the retrochiasmatic location.10-13 Advantages include unhindered access to the retrochiasmatic space without crossing the optic nerve and chiasm. The angle of approach allows visualization superiorly to the hypothalamus. Additionally, the approach shortens the distance to the tumor, allowing for delicate bimanual dissection of the tumor, especially at the basilar artery and hypothalamic interfaces. This video demonstrates three cases of retrochiasmatic craniopharyngioma resection through the petrosal approach, highlighting these advantages to optimize patient outcome. The patients and guardians consented for the surgery, photography, and publication of the patient's image. Figures from Al-Mefty et al11 used with permission from the Journal of Neurosurgery Publishing Group. Additional figures republished from Al-Mefty et al.12 "The petrosal approach for the resection of retrochiasmatic craniopharyngiomas," Neurosurgery, 2008, volume 62, issue 5 Suppl 2 (ONS), ONS331-ONS336, by permission of the Congress of Neurological Surgeons.

Surgical Management of Skull Base and Spine Chordomas

Management of chordoma along the cranial-spinal axis is a major challenge for both skull base and spinal surgeons. Although chordoma remains a rare tumor, occurring in approximately 1 per 1 million individuals, its treatment poses several challenges. These tumors are generally poorly responsive to radiation and chemotherapy, leading to surgical resection as the mainstay of treatment. Due to anatomic constraints and unique challenges associated with each primary site of disease, gross total resection is often not feasible and is associated with high rates of morbidity. Additionally, chordoma is associated with high rates of recurrence due to the tumor's aggressive biologic features, and postoperative radiation is increasingly incorporated as a treatment option for these patients. Despite these challenges, modern-day surgical techniques in both skull base and spinal surgery have facilitated improved patient outcomes. For example, endoscopic endonasal techniques have become the mainstay in resection of skull base chordomas, improving the ability to achieve gross total resection, while reducing associated morbidity of open transfacial techniques. Resection of spinal chordomas has been facilitated by emerging techniques in preoperative imaging, intraoperative navigation, spinal reconstruction, and radiotherapy. Taken collectively, the treatment of chordoma affecting the skull base and spinal requires a multidisciplinary team of surgeons, radiation oncologists, and medical oncologists who specialize in the treatment of this challenging disease.

Multiple skull base defects: features of pathogenesis, diagnosis and treatment

To determine the risk factors of multiple skull base defects, as well as features of diagnosis and treatment of this pathology. A retrospective analysis included 39 patients who underwent surgery for nasal CSF leakage at the Burdenko Neurosurgical Center in 2000-2019. The study recruited patients with multiple simultant skull base defects. Traumatic defects were observed in 23 (59%) patients, spontaneous defects - in 16 (41%) cases. All patients underwent endoscopic endonasal closure of skull base defects with autografts. Multiple defects are more common in severe traumatic brain injury. The main risk factors of multiple spontaneous defects are female sex and overweight. Adequate diagnosis implies high-resolution CT (slice width 0.5-1 mm), as well as intraoperative control of all suspicious and «weak» areas. Endoscopic endonasal technique is effective and safe for multiple skull base defects (efficiency 97%).

Novel concepts and strategies in skull base reconstruction after endoscopic endonasal surgery

&lt;p align="left"&gt;Recently, a variety of craniofacial approaches has been adopted to enter the skull base, among those, the endonasal endoscopic technique. An effective watertight thereafter: the reconstruction can be performed using different materials, both autologous and non-autologous, individually or combined in a multilayer fashion. The current study was focused on the development of new advanced devices and techniques, aiding in reducing postoperative CSF leak rate. Additive manufacturing allows the design of devices with tailored structural and functional features and, as well, injectable semi-IPNs and composites; therefore specific mechanical/rheological and injectability studies are valuable. Accordingly, we propose new additive-manufactured and injectable devices.&lt;/p&gt;

Extended endonasal approaches for pituitary adenomas.

Pituitary adenomas with significant extension beyond the sellar boundary, large size, asymmetrical shape and subarachnoid space invasion, although rare, represent a therapeutic challenge. The invasiveness of the tumor itself often limits the potential for complete tumor resection and increases the likelihood of intraoperative or postoperative complications, regardless of the approach. The extended endoscopic endonasal approach has been proposed as a valid alternative to the transcranial route for the treatment of certain pituitary adenomas not suitable to the standard transsphenoidal approach. Thanks to the wide and close up view provided by the endoscope via the appropriate expanded bone removal at the skull base, this technique offers, in an adequate working space, a safe exposure of the tumor and surrounding anatomical structures, at the supra-, para-, and retro-sellar areas. It stands clear that the primary goal of this approach remains the maximum allowed resection with preservation of neurological and endocrine functions. Herein, we debate the extended endoscopic endonasal technique for the treatment of pituitary adenomas, with the aim of underlying its indications, pitfalls, advantages, and limitations.

Management of Patients With Graves Orbitopathy Using Endonasal Endoscopic Techniques.

The aim of the authors' study is to show their surgical results in orbital decompression using different endonasal endoscopic techniques. These approaches are according to the degree of proptosis and the presence or not of sight threatening. The authors performed 31 orbital decompressions on 20 Graves orbitopathy patients. Average age at surgery was 52 years. There were 5 males and 15 females. Five patients were diagnosed as having severe or for sight-threatening Graves orbitopathy. These included 3 men and 2 women having an average age of 54 years old. Minimum postsurgical follow-up was 12 months in all patients. Orbital decompression was performed in 15 patients for proptosis and in 5 patients for urgent sight threat. Thirteen orbits showed mild proptosis and 18 orbits presented moderate proptosis. In patients without sight threatening reduction of proptosis had a mean value of 2.8 mm as determined by exophtalmometry, being 3.3 mm when measured on magnetic resonance imaging. The mean millimeter in mild proptosis was between 1.5 and 1.7 and between 3.4 and 4.2 in moderate proptosis. In patients having sight threat mean visual acuity after surgery improved from 0.6 to 0.9.Only 1 patient without diplopia preoperative developed diplopia after surgery (17%). In 55% of patients strabismus and/or eyelid surgery were required.In postoperative follow-up, 2 patients developed a mucocele and 1 patient developed corneal erosion. The authors recommend the preservation of the periorbital sling and the anterior ethmoido-maxillary angle in patients with mild-moderate exophthalmos and without threatened vision. In case of sight threatening the authors resected the most periorbita as much as possible.Evidence-based medicine Level V.

Emergency endovascular treatment of cavernous internal carotid artery acute bleeding with flow diverter stent: a single-center experience

Background and objectiveTo describe our single-center experience in the treatment of cavernous internal carotid artery (ICA) acute bleeding with flow diverter stent (FDS), as a single endovascular procedure or combined with an endoscopic endonasal approach.MethodsWe analyze a case series of 5 patients with cavernous ICA acute bleeding, i.e., 3 iatrogenic, 1 post-traumatic, and 1 erosive neoplastic. After an immediate nasal packing to temporarily bleeding control, patients underwent digital subtraction angiography (DSA) to identify the site of the ICA injury. A concomitant balloon occlusion test (BOT) was performed, to exclude post-occlusive ischemic neurological damage. An FDS was placed with parallel intravenous infusion of abciximab in 3 cases and tirofiban in 2 cases. In two patients, an innovative “sandwich technique” combining the endovascular reconstruction with an extracranial intrasphenoidal cavernous ICA resurfacing with autologous flaps or grafts by endoscopic endonasal approach was performed.ResultsNo patient had periprocedural ischemic-hemorrhagic complications. All patients had a regular clinical evolution, without general complications or new onset of focal neurological deficits. No further bleeding occurred in 3 patients, while 2 cases experienced a mild rebleeding in a period ranging from 5 to 15 days after the endovascular procedure. In these two cases, we proceeded with an endoscopic endonasal procedure to resurface the exposed ICA wall in the sphenoid sinus.ConclusionsAlthough the treatment of choice for cavernous ICA acute bleeding remains the occlusion of the injured vessel, in cases of poor hemodynamic compensation at the BTO, the endovascular FDS emergency placement can be effective. A combined endoscopic endonasal technique to support the extracranial side of the vessel using autologous flaps or grafts can be performed to prevent the risk of rebleeding.