Frontobasal Interhemispheric Approach Research Articles

Feasibility of the frontobasal interhemispheric approach for managing large olfactory groove meningiomas

Feasibility of the frontobasal interhemispheric approach for managing large olfactory groove meningiomas

The interhemispheric fissure\u2014surgical outcome of interhemispheric approaches

Exposure of the anterior skull base is challenging due to strategic structures. The interhemispheric approach (IHA) has turned out to be a feasible technique. We report our experience with IHAs in patients with extraaxial lesions (EAL). We performed a retrospective chart review at a tertiary neurosurgical center between April 2009 and March 2020. We included patients with resection of EAL through IHAs concentrating on surgical technique, complete resection rate, postoperative outcome, and complications. Seventy-four patients resected by an IHA were included: 49 (66.2%) frontal (FIA), nine (12.1%) parietooccipital (PIA), and 16 (21.6%) frontobasal IHAs (FBIAs). Median age at time of surgery was 59 years (range 16–88 years), 47 (63.5%) female and 27 (36.5%) male. Complete resection rate was 83.8% (FIA 89.8%, PIA 55.6%, FBIA 81.3%). Rate of new minor deficits was 17.6%, rate of major deficits 5.4%, total rate 23.0%. 51 (68.9%) WHO°I meningiomas, ten (13.5%) WHO°II meningiomas, two (2.7%) WHO°III meningiomas, nine (12.2%) metastases, one (1.4%) sarcoma, and one (1.4%) local adenocarcinoma were resected. Total complication rate was 27.0%. Rate of major complications requiring intervention was 9.6%. Mean follow-up was 34.2 (± 33.2) months. In patients with lesions of the interhemispheric fissure, overall morbidity and complications are comparatively high. Extensions of IHAs with potential even higher morbidity are not necessary though; we support the use of standardized IHAs. Our findings suggest regular usage of relatively feasible IHAs for a satisfying outcome. Invasive, complicated, or contralateral trajectories were not needed.

Removal of craniopharyngioma via fronto-basal interhemispheric approach.

The effectiveness and safety of fronto-basal interhemispheric approach in treating craniopharyngioma were evaluated. In this retrospective study, the safety and effectiveness of fronto-basal interhemispheric approach for surgical resection of craniopharyngioma in 20 patients was analyzed. Of the 20 patients, 12 were men and 8 were women, aged 15–65 years, with an average age of 42.5 years. The course of disease ranged from 1 to 36 months. The craniopharyngioma tumor was completely removed through surgical resection in 18 patients (90%) and partially removed in 2 patients. The pituitary stalk was preserved in 18 patients and 1 patient succumbed during the study period due to large area pulmonary embolism. In conclusion, fronto-basal interhemispheric approach provides better access to the tumor that grows in the sella-hypothalamus and anterior third ventricle region. Using this approach, tumors can be resected while preserving the vital structures such as the pituitary stalk and hypothalamus.

Hybrid Microscopic-Endoscopic Surgery for Craniopharyngioma in Neurosurgical Suite: Technical Notes

The best chance of curing craniopharyngioma is achieved by microsurgical total resection; however, its location adjacent to critical structures hinders complete resection without neurologic deterioration. Unrecognized residual tumor within microscopic blind spots might result in tumor recurrences. To improve outcomes, new techniques are necessary to visualize tissue within these blind spots. We examined the success of hybrid microscopic-endoscopic neurosurgery for craniopharyngioma in a neurosurgical suite. Four children with craniopharyngiomas underwent microscopic resection. When the neurosurgeon was confident that most of the visible tumor was removed but was suspicious of residual tumor within the blind spot, he or she used an integrated endoscope-holder system to inspect and remove any residual tumor. Two ceiling monitors were mounted side by side in front of the surgeon to display both microscopic and endoscopic views and to view both monitors simultaneously. Surgery was performed in all patients via the frontobasal interhemispheric approach. Residual tumors were observed in the sella (2 patients), on the ventral surface of the chiasm and optic nerve (1 patient), and in the third ventricle (1 patient) and were resected to achieve total resection. Postoperatively, visual function was improved in 2 patients and none exhibited deterioration related to the surgery. Simultaneous microscopic and endoscopic observation with the use of dual monitors in a neurosurgical suite was ergonomically optimal for the surgeon to perform microsurgical procedures and to avoid traumatizing surrounding vessels or neural tissues. Hybrid microscopic-endoscopic neurosurgery may contribute to safe, less-invasive, and maximal resection to achieve better prognosis in children with craniopharyngioma.

Identification and protection strategy of pituitary stalk during microsurgery of sellar region tumors

Objective To study the protection strategy of pituitary stalk via transcranial approach for sellar tumors resection.Methods Retrospective analysis of the clinical data of 110 patients with sellar region tumors was performed.Craniotomy was performed via the pterional approach in 34 cases,the subfrontal approach in 21 cases,the supraorbital keyhole approach in 20 cases,the interhemispheric approach in 35 cases (the fronto-basal interhemispheric approach in 26 patients,and the anterior interhemispheric approach through the lamina terminalis in 9 patients).Results In 47 cases with pituitary adenoma,the tumors were totally resection in 42 cases,the pituitary stalks were preserved in 44 cases,partly retained in 2 and not founded in 1.In 38 cases with craniopharyngioma,the tumors were totally removed in 32 cases.The pituitary stalks were preserved in 27 cases,and partly retained in 7 cases and not founded in 4.In 25 patients with Meningioma,the tumors were totally removed in 23 cases,the pituitary stalks were preserved in 24 cases (P ＜ 0.05).Conclusions The nature of tumors directly affect the retention rate of pituitary stalk,so we should choose appropriate surgical approach and skilled microsurgical techniques which play an important role in the identification and protection of pituitary stalk. Key words: Pituitary stalk ; Sellar region tumor ; Craniotomy; Microsurgery

Locating of the Pituitary Stalk for Craniopharyngioma Surgery of Transfrontobasal Interhemispheric Approach

The aim of this study was to provide a relatively safe operation range for the protection of the pituitary stalk in transfrontobasal interhemispheric approach for craniopharyngioma surgery by measuring the related parameters of the pituitary stalk. Based on the whole-head magnetic resonance imaging scans of 119 healthy subjects (57 men and 62 women) anonymously, three-dimensional reconstructions were rebuilt. The results of the study are as follows: M is the common midpoint of anterior and inferior border of anterior commissure. O and P are the midpoint of the anterior border of the pituitary stalk's superior and inferior extremity, respectively. The distance between M and O (D1) was 12.42 (SD, 2.35) mm. The distance between M and P (D2) was 22.47 (SD, 2.57) mm. The length of the pituitary stalk (D3) was 10.68 (SD, 2.34) mm. The widest diameter of the pituitary stalk (D4) was 2.78 (SD, 0.50) mm. The inclination of the pituitary stalk at the coronal plane (A1) was 2.73 (SD, 2.60) degrees. Of the 119 pituitary stalks involved in this study, 14.29% were centered, 47.06% inclined to the left with the value (A1L) of 3.41 (SD, 2.58) degrees and 38.66% inclined to the right with the value (A1R) of 2.93 (SD, 2.49) degrees. The angle between MO and MP(A2) was 11.81 (SD, 4.76) degrees. No statistical difference was found between male and female subjects for all the measurements (P > 0.05). With the parameters measured in this study, we can locate the pituitary stalk by anterior commissure; thus, it is relatively safe to do the craniopharyngioma surgery through frontobasal interhemispheric approach when the pituitary stalk cannot be seen clearly because of the shelter of tumor, which will reduce both the unnecessary damage to the pituitary stalk and the probability of postoperative complications.

Frontobasal interhemispheric approach for large superasellar craniopharyngiomas: do the benefits outweigh the risks?

Large suprasellar craniopharyngiomas are surgically challenging. The aim of our study was to explore the therapeutic efficacy of the frontobasal interhemispheric approach for these lesions. Twenty-nine consecutive adult patients with large suprasellar craniopharyngiomas (diameter >4 cm) who underwent the frontobasal interhemispheric approach were retrospectively evaluated. Surgical and clinical outcomes were analyzed. Gross total removal was achieved in 23 cases (79.3%) and subtotal removal in 6 cases (20.7%). The mean follow-up period was 76.5 ± 33.2 months (range, 12-132 months). Twenty-four patients (82.7%) had improvement of the visual impairment score (VIS) after surgery. VIS was unchanged in five patients (17.3%), and no patients experienced visual deterioration. Among 23 patients who had preoperative hypopituitarism, 8 (34.8%) had an improvement. Postoperative new or aggravated hypopituitarism was observed in four patients (13.8%). Permanent diabetes insipidus was observed in ten patients (34.4%). Postoperative anosmia occurred in two earlier cases (6.9%). There was no intracranial infection or cerebrospinal fluid fistula. At last follow-up, >9% BMI gain was observed in 34.5% of patients, and 65.5% of patients returned to work. Four patients (13.8%) suffered recurrence. Although the frontobasal interhemispheric approach has some disadvantages, it provides ideal access to the suprasellar region and the third ventricle with limited brain retraction. The surgically visible angle is adequate; thus, vital structures can be better protected. For large suprasellar craniopharyngiomas, the benefits of this approach can outweigh its potential risks.

Fronto-basal interhemispheric approach for tuberculum sellae meningiomas; long-term visual outcome

We report our experience with the treatment of tuberculum sellae meningiomas using the fronto-basal interhemispheric approach. A retrospective analysis was performed on a series of 24 patients with tuberculum sellae meningiomas who were operated between March 2000 and January 2007. Patients' presenting symptoms, radiological images, operative reports, and clinical follow-up data were reviewed with special consideration for visual outcome. Visual deterioration was the presenting symptom in all patients, followed by headache in 9 patients (37.5%). The average duration of visual symptoms was 17.6 months. The average tumor diameter was 2.63 cm; encasement of the carotid artery was identified in 7 patients (29%). Complete tumor removal was achieved in 21 patients (87.5%). Mean follow-up period was 52 months. Vision improved in 19 patients (79%), remained stable in 4 (17%) and deteriorated in 1 patient (4%). The degree of tumor removal or visual outcome were both unrelated to the tumor size (p = 0.2 and p = 0.6 respectively). While the degree of preoperative visual deficit did not affect the visual improvement rate in the whole group (p = 0.9), those patients with improvement to good functional vision (>20/40) after the surgery, had a less severe preoperative deficit (p < 0.001). The most common complication was anosmia (29.1%) and there was no mortality. The frontobasal interhemispheric approach is safe and provides a direct anatomical approach to tuberculum sellae meningiomas with relatively low incidence of complications. Patients with improved vision to good functional level had a better preoperative visual status.

FRONTOBASAL INTERHEMISPHERIC TRANS-LAMINA TERMINALIS APPROACH FOR SUPRASELLAR LESIONS

The frontobasal interhemispheric approach for suprasellar tumors currently incorporates technological advancements and refinements in patient selection, operative technique, and postoperative care. This technique is a valid choice for the removal of suprasellar lesions with extension into the third ventricle without major sequelae related to the surgical approach. The method described here reflects the combination of the frontal interhemispheric and trans-lamina terminalis approaches.

Severe Amnesic Syndrome and Collecting Behavior After Surgery for Craniopharyngioma

Significant neuropsychologic sequelae were induced by total removal of craniopharyngioma via a frontobasal interhemispheric approach. A 50-year-old right-handed man developed severe amnesic syndrome and collecting behavior after total removal of a craniopharyngioma. He had very poor results on tests of learning, recall, and recognition for both verbal and nonverbal tasks. Magnetic resonance imaging revealed damage to the bilateral mammillary bodies and fornices, and N-isopropyl-p-[23I]iodoamphetamine single photon emission computed tomography showed decreased cerebral blood flow in the bilateral frontal lobes, predominantly in the right, and regions around the third ventricle. The present case suggests that damage to the brain structures surrounding the third ventricle associated with surgery for craniopharyngioma may result in amnesic syndrome and collecting behavior. Generally, the frontobasal interhemispheric approach is the optimum choice for the removal of craniopharyngioma without significant sequelae related to the surgical method, but the risk of neuropsychologic disturbances must be kept in mind.

Microsurgical treatment of craniopharyngiomas: report of 284 patients

Generally, total surgical removal of craniopharyngioma results in satisfactory outcome with a low recurrence rate, however, the location of the tumor and its adherence to the hypothalamic structures can make the operation difficult. The goal of the present study was to assess the outcome of craniopharyngiomas in 284 patients treated surgically. A total of 284 patients (151 men and 133 women) with craniopharyngioma were treated surgically by our neurosurgeons from January 1996 to March 2006. Among them, 226 (79.6%) patients were adults (15 years of age or older; mean, 35.8 +/- 10.6), 58 (20.4%) were children (14 years of age or younger; mean, 9.1 +/- 3.8). The diameter of the tumors were 2.0 - 9.0 cm (mean, 36.54 +/- 11.4). The tumors were classified into the superior (23 patients) and inferior ventricular (261) types according to the location of the tumor relative to the third ventricular floor. For the patients with craniopharyngioma of inferior ventricular type, pterional approach was used in 191 (67.3%) patients, subfrontal approach in 17 (6.0%), and translamina terminalis through frontobasal interhemispheric approach in 53 (18.7%). For those with the tumors of superior ventricular type, transcallosal approach into the anterior third ventricle was done in 10 (3.5%) patients, and the lamina terminalis approach in 13 (4.6%). Of the 284 patients, 204 (71.8%) were followed up for 0.5 to 8 years (mean, 2.1 +/- 1.8), including 162 patients received total tumor removal, and 37 underwent subtotal or partial removal. Total, subtotal and partial removal of the tumors were achieved in 237 (83.5%), 34 (12.0%) and 13 (4.5%) patients, respectively. The pituitary stalk was preserved in 176 (62.0%) patients, severed in 52 (18.3%), and unidentified in 56 (19.7%). Twelve (4.2%) patients died within one month after the surgery. During the follow-up, 23 (14.1%) patients experienced tumor recurrence 1.0 - 3.5 years (mean, 1.8 +/- 1.6) after total tumor removal, and 24 (64.9%) had recurrent tumor 0.25 - 1.5 years (mean, 0.5 +/- 0.4) after subtotal or partial resection. Normal activities of daily living were regained in 63 (80%) patients, independence in 29 (14.2%), and daily life with assistance in 9 (4.4%). Four (2.0%) patients died 0.9 - 3 years (mean, 1.6 +/- 1.4) after discharge from hospital, 3 of them died of hypothalamic deficiency. We can protect the hypothalamic structures and its perforating arteries by choosing surgical approaches according to the location of craniopharygioma relative to the third ventricular floor. The mortality, morbidity, and recurrence rate in patients received total resection are lower than those of patients underwent subtotal or partial resections. In addition, preservation of the pituitary stalk is critical when total tumor resection is feasible.

Fronto-basal interhemispheric approach for craniopharyngiomas extending outside the suprasellar cistern

The aim of the present study was to establish the usefulness of the fronto-basal approach with a relatively small craniotomy window for the removal of tumors protruding from the sellar-suprasellar region to the third and basal cistern. Forty-two patients who were surgically treated for craniopharyngiomas extending outside the sellar-suprasellar region were evaluated. All the patients were operated on by the fronto-basal interhemispheric approach, and the average follow-up period was 5 years. Gross total resection of the lesion was achieved in 30 cases. Eight patients underwent subtotal resection and four patients underwent partial removal due to recurrence after previous surgeries with or without radiotherapy. In the immediate postoperative period, major complications, including impairment of the cranial nerves, were observed in two cases. One patient exhibited transient memory disturbance due to infarction of the perforator; after 3 months, this symptom was ameliorated. Three of the patients died during follow-up; however, 6 of the 30 undergoing gross total removal and 10 of the 12 patients undergoing subtotal or partial removal suffered regrowth. Ultimately, a total of 12 patients underwent re-operation with the same approach or combined with the orbito-zygomatic approach. In our experience, the fronto-basal interhemispheric approach, even through a small craniotomy window, is a valid choice for the removal of craniopharyngiomas extending outside the sellar-suprasellar region. Using this approach, tumors can be removed without significant sequelae related to surgical technique due to easy preservation of the pituitary stalk, hypothalamic structures, and perforators. This approach offers a safe and minimally invasive means of treating craniopharyngiomas.

Frontobasal Interhemispheric Trans-Lamina Terminalis Approach for Suprasellar Lesions

The frontobasal interhemispheric approach for suprasellar tumors currently incorporates technological advancements and refinements in patient selection, operative technique, and postoperative care. This technique is a valid choice for the removal of suprasellar lesions with extension into the third ventricle without major sequelae related to the surgical approach. The method described here reflects the combination of the frontal interhemispheric and trans-lamina terminalis approaches.

Ectopic recurrence of craniopharyngioma

A 50-year-old woman first presented with recurrent craniopharyngioma in the suprasellar region. The recurrent tumor was removed via the frontobasal interhemispheric approach. Two years later, magnetic resonance imaging revealed a further recurrence in the primary suprasellar region and a cystic mass with ring enhancement on the surface of the left frontal lobe. Both lesions were removed via the frontobasal interhemispheric approach. Histological examination showed the left frontal lesion was an ectopic recurrence of craniopharyngioma. Ectopic recurrence of craniopharyngioma is extremely rare.

Surgery for craniopharyngiomas extending outside the suprasellar cistern

Objective: Craniopharyngiomas frequently grow from remnants of Rathke's pouch, located on the cisternal surface of the hypothalamic region. They can extend elsewhere in the infundibulo-hypophyseal axis. The aim of the present study was to establish the usefulness of the fronto-basal approach with a relatively small craniotomy window for the removal of tumors protruding from the sellar–suprasellar region to the third and basal cistern. Method: Thirty-one patients who were surgically treated for craniopharyngiomas extending outside the sellar–suprasellar region were evaluated. The diagnoses were established in all cases with magnetic resonance imaging and CT. The initial symptoms and signs were increased intracranial pressure in 17 patients, vision impairment or visual field defect in 15, hypopituitarism in 13, and psychological disturbances in 4 cases. All the patients were operated on by the fronto-basal interhemispheric approach, and the average follow-up period was 30 months. Results: Total removal of the lesion was achieved in 22 cases. Six patients underwent subtotal resection and 3 patients underwent partial removal due to recurrence after previous surgeries with or without radiotherapy. In the immediate postoperative period, major complications, including impairment of the cranial nerves, were not observed. One patient exhibited transient memory disturbance due to infarction of the perforator; after 3 months, this symptom was ameliorated. None of the patients died during long-term follow-up (average 30 months), however 4 of the 22 undergoing total removal and 6 of the 9 patients undergoing subtotal or partial removal suffered recurrence. Of the 10 patients with recurrence, 6 experienced a small recurrence of the lesion (average 3 months after surgery); after radiosurgery by gamma-knife, 2 of the lesions exhibited unchanged size and 4 underwent re-operation due to enlargement of the tumor in the follow-up period. Ultimately, a total of eight patients (four with recurrence and four gamma-knife-treated) underwent re-operation with gross total removal with the same approach or combined with the orbito-zygomatic approach for patients with very short optic nerves. All patients returned to a normal life. Conclusion: In our experience, the fronto-basal interhemispheric approach, even through a small craniotomy window, is a valid choice for the removal of craniopharyngiomas extending outside the sellar–suprasellar region. Using this approach, tumors can be removed without significant sequelae related to surgical technique due to easy preservation of the pituitary stalk, hypothalamic structures and perforators. This approach offers a safe and minimally invasive means of treating craniopharyngiomas.