Subfrontal Approach Research Articles

Surgical outcome of clipping in anterior circulation aneurysms.

To observe the outcome of surgical clipping in anterior circulation aneurysm in a modestly resourced hospital. A retrospective cross-sectional study was conducted at Punjab Institute of Neurosciences Lahore, from August 2022 to July 2023. Seventy five patients meeting the inclusion criteria of age <65, saccular aneurysm of anterior circulation, and Hunt and Hess grade one or two were enrolled through non-probability convenience sampling. Data were collected from patient records, and surgeries were performed by experienced neurosurgeons using pterional and sub-frontal approaches. SPSS version 26 was utilized for data analysis. Mean age 49.3733 ± 2.56 (Mean ± SD) years, 60% female. Most common aneurysm location: anterior communicating artery (37.33%). Post-operative complications: vasospasm (17.33%), hydrocephalus (6.66%), fits (5.33%), mortality (2.66%). About 91% patients had no complications or recovered within three months. Surgical clipping of anterior circulation aneurysms is a safe and effective treatment, yielding favorable angiographic outcomes. Despite occasional complications, most patients achieved satisfactory results, especially in a setting having limited endovascular facilities or when coiling is not feasible. Future comparative studies with endovascular methods will further refine patient selection and surgical techniques.

Microsurgical Treatment of Intracranial Dural Arteriovenous Fistulas: A Collaborative Investigation From the Multicenter Consortium for Dural Arteriovenous Fistula Outcomes Research.

First-line therapy for most intracranial dural arteriovenous fistulas (dAVFs) is endovascular embolization, but some require microsurgical ligation due to limited endovascular accessibility, anticipated lower cure rates, or unacceptable risk profiles. We investigated the most common surgically treated dAVF locations and the approaches and outcomes of each. The Consortium for Dural Arteriovenous Fistula Outcomes Research database was retrospectively reviewed. Patients who underwent dAVF microsurgical ligation were included. Patient demographics, angiographic information, surgical details, and postoperative outcomes were collected. The 5 most common surgically treated dAVF locations were analyzed about used surgical approaches and postoperative outcomes. Univariate analyses were performed with statistical significance set at a threshold of P < .05. In total, 248 patients in the Consortium for Dural Arteriovenous Fistula Outcomes Research database met inclusion criteria. The 5 most common surgically treated dAVF locations were tentorial, anterior cranial fossa (ACF), transverse-sigmoid sinus (TSS), convexity/superior sagittal sinus (SSS), and torcular. Most tentorial dAVFs were approached using a suboccipital, lateral supracerebellar infratentorial approach (39.3%); extended retrosigmoid approach (ERS) (25%); or posterior subtemporal approach (19.6%). All ACF dAVFs used a subfrontal approach; 5.3% also included an anterior interhemispheric approach. Most TSS dAVFs were ligated via ERS (31.3%) or subtemporal (31.3%) approaches. All convexity/SSS dAVFs used an interhemispheric approach. All torcular dAVFs used the suboccipital, lateral supracerebellar infratentorial approach, with 10.5% undergoing simultaneous ERS craniotomy. Angiographic occlusion rates after microsurgery were 85.5%, 100%, 75.8%, 79.2%, and 73.7% for tentorial, ACF, TSS, convexity/SSS, and torcular dAVFs, respectively (P = .02); the permanent neurological complication rates were 1.8%, 2.6%, 9.1%, 0%, and 0% (P = .31). There were no statistically significant differences in development of complications (P = .08) or Modified Rankin Scale at the last follow-up (P = .11) by fistula location. Although endovascular embolization is the first-line treatment for most intracranial dAVFs, surgical ligation is an important alternative. ACF and tentorial fistulas particularly demonstrate high rates of postoperative obliteration.

Anatomy and Microsurgical Relevance of the Outer Arachnoid Envelope around the Olfactory Bulb Based on Endoscopic Cadaveric Observations.

There is high risk of injury to the olfactory tract and olfactory bulb during surgery of the anterior cranial fossa. The goal of this study was to describe the outer arachnoid envelope around the olfactory bulb, which plays a significant role in approach-related injury of the nerve. A total of 20 fresh human cadaveric heads were examined. Five cadaveric heads were used to describe a gross overview of the topographic anatomy of the outer arachnoid cover of the olfactory bulb. In 15 cadaveric heads, endoscopic surgical approaches were performed to examine the in situ undisrupted anatomy of the outer arachnoid around the olfactory bulb. Four cadaveric heads were used for the lateral subfrontal approach, 5 heads for the medial subfrontal approach, 3 heads for the median subfrontal approach, and 3 heads for the anterior interhemispheric approach. The outer arachnoid membrane of the frontal lobe attaches the olfactory bulb strongly to the above lying olfactory sulcus. Only the most rostral portion of the olfactory bulb became slightly detached from the frontal lobe. The outer arachnoid forms a decent protrusion around the tip of the olfactory bulbs. The fila olfactoria have their own outer arachnoid cover as a continuation of the same layer of the olfactory bulb. The effect of brain retraction and manipulation forces on the olfactory bulb and the role of the arachnoid membranes located here were visually analyzed and described in detail through the four different neurosurgical approaches we performed. The results of our observations provide important anatomical details for preserving the sense of smell during neurosurgical procedures.

"Open-window" craniectomy for the removal of frontal sinus mucosa to prevent a delayed mucocele: illustrative case.

Frontal craniotomies for a medial subfrontal approach necessitate crossing the frontal sinus. Large superior extensions of the frontal sinus into frontal bone can result in mucosal retention in a free craniotomy bone flap, leading to a delayed mucocele with significant associated morbidity. The authors describe an "open-window" craniectomy technique that permits mucosal removal under direct vision and maintains the inner table on the bone flap's inferior side, helping to seal off the sinus opening with a pericranial flap. An illustrative case involving a medial right frontal craniotomy for a third ventricle mass in a patient with a large superior extension of the frontal sinus into frontal bone is presented. After creating a free frontal bone flap, the inner table was drilled out to the margins of the frontal sinus cavity and any remaining mucosa was cleared. A portion of the inner table above the bone flap's inferior margin was left in place, resembling an open window when viewed from the inner table side. The remaining anterior and posterior wall of the flap inferiorly provided a matched surface for the opening into the remaining frontal sinus, which was covered by pericranium. Long-term follow-up indicated no major complications or delayed mucocele. The open-window craniectomy technique can be considered for frontal sinus violations in patients with large superior frontal bone extension.

Pediatric skull base tumors: Clinical features and surgical outcomes; a single center retrospective study with a review of literature

ObjectivesPediatric intracranial tumors, particularly at the skull base, are rare and present unique challenges to pediatric neurosurgeons and oncologists, owing to their complex anatomy and diverse histopathology. Robust evidence is still marginal concerning their clinical and surgical courses. Our aim is to describe our experience regarding surgical approaches, with special focus on surgical features, postoperative outcomes, adverse events as well as adjuvant therapeutic concepts. MethodsPatients aged <18 years undergoing skull base surgery between 2017 and 2023 at our institution were retrospectively enrolled. Patient demographics, tumor characteristics, surgical approach, pre -and postoperative clinical status and adjuvant therapy as well as overall and progression free survival were assessed. ResultsTwelve children aged 6.1 ± 4.1 years were analyzed. There was a predominance of the female gender (7/12, 58.4%). Mean tumor diameter was 4.0 ± 2.9 cm. In three children the tumor was located suprasellar, temporobasal in one, adjacent to the cerebellar pontine angle in 4, clival in 3 and petroclival in 2 children. A subfrontal approach was performed in two patients, a subtemporal approach in one, a retrosigmoidal approach in 5 and in one patient two-staged approach; retrosigmoidal and later in a second operation pterional approach was conducted. One clival tumor was removed via an endonasal endoscopic approach and in another case via a transoral endoscopic approach. Gross total resection (GTR) and near total resection were achieved in 7 patients (58.3%). Tumor types included meningioma, clivus-chordoma, epidermoid cyst, anaplastic ependymoma, Ewing's sarcoma and Atypical Teratoid Rhabdoid Tumor (ATRT) as well as embryonal tumor with multilayered rosettes (ETMR). 4 patients (33.3%) died of disease due to tumor progression in average after 15 months. Hydrocephalus developed in two patients; a ventriculoperitoneal shunt was inserted in one patient, while an endoscopic third ventriculostomy (ETV) was performed in the other. Moreover, one child suffered from a residual neurological deficit at last follow-up evaluation. Adjuvant therapy protocols were applied in six patients (50.0%). ConclusionSkull base tumors in children present a therapeutic challenge due to their rarity and unique pathological composition and can lead to considerable morbidity and mortality. An interdisciplinary approach involving neurosurgeons, pediatric oncologists and radiotherapists is mandatory to guarantee the best clinical course.

Surgical Strategies in the Treatment of Giant Pituitary Adenomas.

The management of giant pituitary adenomas (GPAs) is challenging due to associated endocrinopathies and the close proximity of these tumors to critical structures, such as the optic nerves, structures of the cavernous sinus, and hypothalamus. The objective of this review article was to summarize the current management strategies for giant pituitary adenomas, including the role of open and endoscopic surgical approaches and the role of medical and radiation therapy in conjunction with surgery. We conducted a retrospective review of GPAs operated at our institute between January 2010 and March 2023. Surgical approaches, extent of resection, and associated complications were documented. Furthermore, we conducted a thorough literature review to identify relevant studies published in the past decade, which were incorporated along with insights gained from our institutional case series of GPAs to analyze and integrate both the existing knowledge base and our institution's firsthand experience in the management of GPAs. A total of 46 giant pituitary adenomas (GPAs) were operated on, using various surgical approaches. Transsphenoidal approach was used in 25 cases and a staged approach using transsphenoidal and pterional was used in 15 cases. Other approaches included transcortical-transventricular, transcallosal, pterional/orbitozygomatic, and subfrontal approaches. Complications and technical nuances were reported. The management of giant pituitary adenomas remains complex, often involving several modalities-open or endoscopic resection, radiosurgery, and medical management of both the tumor and associated endocrinopathies. Surgical resections are often challenging procedures that require careful consideration of several factors, including patient characteristics, tumor location, and size, and the experience and skill of the surgical team.

Transglabellar resection of frontal sinus cholesterol granuloma extending cranially through cecum foramina: Technical note.

Cholesterol granuloma (CG) commonly occurs in the petrous apex; their occurrence in the anterior cranial fossa CGs is rare. Subfrontal approaches are the conventional surgical approaches for the resection of midline lesions of the anterior cranial fossa and frontal sinuses. In this article, we describe a successful minimally invasive approach for resection of a small midline anterior cranial fossa CG. We report a rare case of frontal air sinus CG extending intradurally through the foramen caecum. The surgical management of this patient involved the use of a minimally invasive transglabellar approach and a butterfly incision and the patient outcomes at 1 year after the surgery. The lesion was totally resected with no complications and the patient was discharged on the 3rd postoperative day. A 1-year follow-up scan showed neither residual nor recurrence of the lesion. The transglabellar approach through a butterfly incision offers a safe approach for the resection of a lesion extending from the frontal air sinuses to the anterior cranial fossa with no complications, shorter hospital stay, and good cosmetic results.

Outcome of extradural devascularization in resection of giant olfactory groove meningioma in bilateral subfrontal approach

BackgroundOlfactory groove meningioma (OGM) is characterized by slow-growing tumors that are frequently bilateral as opposed to unilateral & asymmetrical and may cause progressive frontal lobe compression. We aimed to evaluate the value of extradural devascularization as a golden step in bilateral subfrontal approach in management of OGM.ResultsThe mean operative time was 158.32 ± 24.88. Blood loss ranged from 500 to 1000 cc with a mean value of 763.64 ± 155.98. The number of patients requiring blood transfusion was 5 (22.7%). Based on Simpson classification, 19 (86.4%) patients had whole tumor excision (grade I, II) & 3 (13.6%) patients had grade III and IV. The incidence of complications among the studied patients is: CSF leak did not occur to any case, pneumocephalus occurred in 1 (4.5%) patient, anosmia occurred in 1 (4.5%) patient, focal CNS deficit occurred in 1 (4.5%) patient, wound infection occurred in 1 (4.5%) patient and hematoma occurred in 1 (4.5%) patient. Only 1 (4.5%) case died due to pulmonary embolism, whereas behavioral manifestations occurred in 9.09% of patients.ConclusionsThe extradural devascularization is a golden step in this approach in management of OGM associated with lower incidence of blood loss intraoperatively (total blood loss was 500–1000 mL, recurrence rate, mortality and additional neurological deficits postoperatively.

PITUITARY ABSCESS – A RARE CASE REPORT

Study Design: Case Report To report a rare case of Pituitary Abscess, its management and Objective: outcome. A 15-year-old boy Background: presented with history of headache on and off for the past 9 months. MRI revealed a peripheral rim enhancing lesion in the sellar region. Patient underwent Right Frontal Craniotomy, Subfrontal Approach wherein there was pus in the sellar region which was aspirated. Patient was started on antibiotic therapy and on follow up patient got relieved of his symptoms. Pituita Conclusion: ry Abscess is a very rare disease of the sellar region that is difcult to correctly diagnose on the basis of clinical manifestations and MRI. Despite its rareness, a Pituitary Abscess must be considered in the case of a pituitary mass associated with signs of raised Intracranial Pressure with/without pituitary hormone dysregulation and signs of infection. The treatment is a combination of surgery, antibiotics, and hormone substitution whenever needed

A Step-by-Step Dissection of Cerebral Pathologies for Neurosurgical Trainees: The Middle Cerebral Artery Bifurcation Aneurysm.

Aneurysmal subarachnoid hemorrhage remains one of the most prevalent causes of strokes in the young causing a high socioeconomic damage. Both emergent and elective treatments of intracranial aneurysms remain essential challenges for neurovascular centers. We aim to present conceptual education on clip ligation of middle cerebral artery bifurcation aneurysms in an accessible and structured way to maximize the educational takeaway of residents from aneurysm cases. After 30 years of experience of the senior author in cerebrovascular surgery in three centers, we closely reviewed an exemplary case of elective right middle cerebral artery bifurcation aneurysm clipping and contrasted it to an alternative microneurosurgical approach to illustrate key principles of microneurosurgical clip ligation for neurosurgical trainees. Dissection of the sylvian fissure, subfrontal approach to the optic-carotid complex, proximal control, aneurysm dissection, dissection of kissing branches, dissection of aneurysm fundus, temporary and permanent clipping, as well as aneurysm inspection and resection are highlighted as key steps of clip ligation. This proximal-to-distal approach is contrasted to the distal-to-proximal approach. Additionally, general principles of intracranial surgery such as use of retraction, arachnoid dissection, and draining of cerebrospinal fluid are addressed. Due to a constantly decreasing case load in the era of neurointerventionalism, the paradox of facing increased complexity with decreased experience must be met with a sophisticated practical and theoretical education of neurosurgical trainees early on and with a low threshold.

Contralateral subfrontal approach for tuberculum sellae meningioma: techniques and clinical outcomes.

Tuberculum sellae meningiomas (TSMs) present a burdensome surgical challenge because of their adjacency to vital neurovascular structures. The contralateral subfrontal approach provides an outstanding corridor for removing a TSM with an excellent visual outcome and limited complications. The authors present their long-term surgical experience in treating TSMs via the contralateral subfrontal approach and discuss patient selection, surgical techniques, and clinical outcomes. Between 2005 and 2021, the authors used the contralateral subfrontal approach in 74 consecutive patients presenting with TSMs. The surgical decision-making process and surgical techniques are described, and the clinical outcomes were retrospectively analyzed. The mean patient age was 54.4 years, with a female predominance (n = 61, 82%). Preoperatively, 61 patients (82%) had vision symptoms and 73 (99%) had optic canal invasion by tumor. Gross-total resection was achieved in almost all patients (n = 70, 95%). The visual function improvement and stabilization rate was 91% (67/74). Eight patients (11%) showed a worsening of visual function on the less-compromised (approach-side) optic nerve. There was no occurrence of cerebrospinal fluid leakage. Four patients (5%) experienced recurrences after the initial operation (mean follow-up duration 63 months). There were no deaths in this study. The contralateral subfrontal approach provides a high chance of complete tumor removal and visual improvement with limited complications and recurrences, especially when the tumor is in a unilateral or midline location causing unilateral visual symptoms or bilateral asymmetrical visual symptoms, regardless of tumor size or encasement of major vessels. With the appropriate patient selection, surgical technique, and familiarity with surrounding neurovascular structures, this approach is reliable for TSM surgery.

Proposed System for Selection of Surgical Approaches for Craniopharyngiomas Based on the Optic Recess Displacement Pattern

Craniopharyngiomas remain surgically challenging because of the strong adhesion to vital neurovascular structures. We propose a system for the selection of surgical approaches based on the optic recess (OR) displacement pattern to facilitate the surgical planning and obtain the optimum visual and endocrinological outcomes. Craniopharyngiomas were divided into three types based on the OR displacement pattern: superior, anterior, and involvement types. Selected surgical approaches and patient outcome were retrospectively reviewed according to these classifications. Visual and endocrinological outcomes were compared between the groups. This study included 26 patients with primary craniopharyngiomas who underwent surgery at our institution, classified into 11 anterior, 11 superior, and 4 involvement types. Extended endoscopic endonasal approach provided excellent exposure infero-dorsal aspect of the chiasm for manipulation of the dissection plane in the anterior and superior types with midline location. Unilateral subfrontal approach was required for tumor of the superior type with lateral extension. Interhemispheric translamina terminalis approach (TLA) could provide safe dissection under direct vision of strong adhesion at the superior aspect of the chiasm in the involvement type. Visual and endocrinological outcomes were better in the involvement type compared with the superior and anterior types. Visual outcome was significantly correlated with preoperative visual function. Craniopharyngiomas with the involvement type are indicated for TLA to achieve the best visual and endocrinological outcome. Our classification of OR displacement pattern is useful to select the optimal surgical approach for craniopharyngiomas more accurately and concisely, especially in cases with third ventricular extension.

Suprasellar Tumor-Craniotomy

Surgical procedures for pediatric suprasellar tumors include craniotomy and nasal surgery. Craniotomies are increasingly performed with a microscope, exoscope, and endoscope, while nasal surgery is performed mainly with endoscopes. In some cases, craniotomy and nasal surgery are performed together. This article describes craniotomy. Due to its large surgical field, craniotomy is often chosen for large tumors in the suprasellar region, tumors located above the optic chiasm and optic nerve, tumors extending laterally, and hypervascularized tumors. It is the surgical technique of choice for many neurosurgeons because they are familiar with it. Craniotomies include bilateral frontal and frontotemporal craniotomies. The interhemispheric and subfrontal approaches involve bilateral frontal craniotomy, pterional approach, orbitozygomatic approach, subtemporal approach using temporal-occipital craniotomy, and transpetrosal transtentorial approach using temporal-occipital-suboccipital craniotomy. The approach was selected based on the direction of tumor extension and relationship between the tumor and optic nerve, optic chiasm, and blood vessels. This paper describes the frequently used interhemispheric and pterional approaches based on our experience.

Extended endoscopic endonasal approach for resecting anterior intrinsic third ventricular craniopharyngioma.

BackgroundThe surgical treatment of the extended endoscopic endonasal approach (EEEA) is a safe and effective treatment for suprasellar craniopharyngiomas. However, due to damage to the hypothalamus and third ventricle floor (TVF), EEEA is generally regarded as unsuitable in treating intrinsic third ventricle craniopharyngioma (ITVC) that is entirely within the third ventricle. Until now, there have been only a small number of reports using EEEA to treat TVC via a supra-infrachiasmatic approach. Given that the translamina terminalis (TLT) corridor was used in the transcranial subfrontal approach, EEEA via a suprachiasmatic approach may be feasible and practical to treat ITVC. In the current study, we accumulated experience applying the suprachiasmatic translamina terminalis (STLT) corridor for anterior treatment of ITVC.MethodsFrom March 2016 to December 2020, 14 patients with ITVC in our center were analyzed retrospectively. All patients underwent surgery by EEEA via an STLT corridor. The multilayer reconstruction technique was adopted to achieve skull base reconstruction. Data concerning the patient’s tumor resection, vision, hypophyseal hormone, and complications were collected.ResultsGross-total resection was achieved in 13 (92.8%) of14 patients, with achievement of near-total (90%) resection in the remaining 1 patient. Nine cases (64.3%) were papillary craniopharyngiomas, and the other 5 cases were adamantinomatous subtypes. Postoperatively, 3 patients with pituitary insufficiency received hormone replacement therapy. No permanent diabetes insipidus or hypothalamic obesity was found. All pairs showed significant improvement or stability in vision except 1 patient who encountered visual deterioration. No other neurological deficit occurred postoperatively. Observation results for the exudation of nasal tissue and the length of hospitalization were satisfactory. After a mean follow-up period of 26.2 months, tumor recurrence was not observed.ConclusionTLT is a minimally invasive corridor used in EEEA for treating anterior ITVC without increasing risks of visual and hormonal deficits. The multilayered reconstruction technique we used is a safe and effective method for achieving watertight closure and avoiding cerebrospinal fluid leaks and infection. The endonasal approach via STLT provides a new, safe and efficacious operative strategy that should be considered a surgical alternative in treating ITVC.

Individualized surgical treatment of giant tuberculum sellae meningioma: Unilateral subfrontal approach vs. endoscopic transsphenoidal approach.

Giant tuberculum sellae meningiomas (TSMs) are deeply located in the suprasellar region and extensively compressed or encased in the surrounding neurovascular structures, making gross total resection (GTR) without postoperative visual impairment challenging. The authors presented individualized unilateral subfrontal approach and endoscopic transsphenoidal approach (ETSA) in a series of patients and elaborated on their advantages and indications in resecting giant TSMs. A total of 38 patients with giant TSMs operated by a single surgeon between March 2012 and November 2021 were retrospectively reviewed. Patients underwent unilateral subfrontal approach and ETSA according to preoperative imaging characteristics. Tumor characteristics, surgical details, preoperative symptoms, and neurological outcomes of TSMs patients were collected and analyzed. In 31 patients operated with the unilateral subfrontal approach, total resection (Simpson grade I or II) was achieved in 27 patients (87.0%), while 6 patients (85.7%) achieved GTR in 7 patients using ETSA. The postoperative visual improvement was maintained in 22 (81.5%) and 5 patients (83.3%). Recurrence or progression was only observed in 2 (7.4%) patients operated with the unilateral subfrontal approach. There was no mortality in our series. Preoperative imaging and visual function are important for surgical approach selection. Maximum tumor resection and optic nerve protection can be achieved concurrently by taking advantage of these surgical approaches. The cerebral artery protection strategies and individualized surgical techniques provide great utility in improving a patient's quality of life.

Risk Factors for Postoperative Brain Contusion and Early Outcomes in Patients with Anterior Skull Base Meningiomas Undergoing Unifrontal Surgery: Single Center Experience with 110 Patients.

Though frontal lobe contusion is a major cause for morbidity and prolonged hospitalization following excision of anterior skull base meningiomas, there is only limited literature on this complication. This study aimed to find out the incidence of postoperative frontal lobe contusion, identify the risk factors for its development and its impact on early postoperative outcome. Data from 110 patients who underwent excision of anterior skull base meningiomas through a unilateral supraorbital craniotomy from 2001 to 2018 were retrospectively analyzed. The risk factors analyzed for development of postoperative contusion were tumor location, size, volume, peritumoral edema, tumor consistency, extent of resection, tumor grade and type of retraction used. Simpson grade II excision was achieved in ninety-two patients (83.6%). There was no frontal lobe contusion in eighty-two patients (74.5%). Frontal lobe contusion was noted in twenty-eight patients (25.5%), but was severe in only four patients (3.6%). On multivariate analysis, fixed retractor use (OR 11.56 [1.21-110.03]; P =0.03) and WHO grade II tumor (OR 3.29 [1.11-9.77]; P =0.03) were independently associated with postoperative frontal lobe contusion. Patients with higher contusion grade had significantly longer postoperative hospitalization (P =.02) and lower KPS score at discharge (P =.01). Unilateral supraorbital craniotomy and lateral subfrontal approach is an excellent procedure for excision of anterior skull base meningiomas with minimal postoperative complications related to frontal lobe retraction. Frontal lobe contusion should be avoided with the use of dynamic retraction, since postoperative contusion prolongs hospitalization and worsens the functional outcome at discharge.

Tuberculum Sellae Meningiomas: Transcranial Approaches Results and Complications

Objective: Tuberculum sellae meningiomas constitute about 5% - 10% of intracranial meningiomas. They are difficult to treat, owing to their close association with the optic nerves, chiasma, and major cerebral arteries. This retrospective study aims to report on the clinical outcome after transcranial approach for treatment of tuberculem sellae meningiomas at our hospital. Patients and Methods: We reviewed patients with tuberculem sellae meningiomas and underwent transcranial surgical approaches for their lesions at Sohag university hospitals over a 4 years period starting from January 2018. The patients’ clinical and radiological data, operative details, degrees of tumor removal, outcomes and complications were reported. Results: There were 17 patients with tuberculem sellae meningiomas with a mean age of 46.3 years. Female patients constituted 70% of cases. Pterional approach was used in 59% of cases and unilateral subfrontal approach was used in 41% of cases. Gross total tumor removal was achieved in 82% of cases. Visual acuity improved in 47%, remained unchanged in 41%, and worsened in 5.9% of patients. Transient post-operative diabetes inspidus and post-operative haematoma in tumor bed each occurred in 5.9% of patients. Conclusion: Transcranial removal of tuberculum sellae meningioma is still considered the standard approach, with high rate of gross total resection and better visual outcome and low mortality and morbidity.

90-Day Bundled Payment Simulation, Health Care Utilization, and Complications following Craniopharyngioma Resection in Adult Patients.

Context Bundled payment and health care utilization models inform cost optimization and surgical outcomes. Economic analysis of payment plans for craniopharyngioma resection is unknown. Objective This study aimed to identify impact of endocrine and nonendocrine complications (EC and NEC, respectively) on health care utilization and bundled payments following craniopharyngioma resection. Design This study is presented as a retrospective cohort analysis (2000-2016) with 2 years of follow-up. Setting The study included national inpatient hospitalization and outpatient visits. Patients Patients undergoing craniopharyngioma resection were divided into the following four groups: group 1, no complications (NC); group 2, only EC; group 3, NEC; and group 4, both endocrine and nonendocrine complications (ENEC). Interventions This study investigated transphenoidal or subfrontal approach for tumor resection. Main Outcome Hospital readmission, health care utilization up to 24 months following discharge, and 90-day bundled payment performances are primary outcomes of this study. Results Median index hospitalization payments were significantly lower for patients in NC cohort ($28,672) compared with those in EC ($32,847), NEC ($36,259), and ENEC ($32,596; p < 0.0001). Patients in ENEC incurred higher outpatient services and overall median payments at 6 months (NC: 38,268; EC: 49,844; NEC: 68,237; and ENEC: 81,053), 1 year (NC: 46,878; EC: 58,210; NEC: 81,043; and ENEC: 94,768), and 2 years (NC: 58,391; EC: 70,418; NEC: 98,838; and ENEC: 1,11,841; p < 0.0001). The 90-day median bundled payment was significantly different among the cohorts with the highest in ENEC ($60,728) and lowest in the NC ($33,089; p < 0.0001). Conclusion ENEC following surgery incurred almost two times the overall median payments at 90 days, 6 months, 1 year. and 2 years compared with those without complications. Bundled payment model may not be a feasible option in this patient population. Type of complications and readmission rates should be considered to optimize payment model prediction following craniopharyngioma resection.

Minimally Invasive Subfrontal Approach: How to Make it Safe and Effective from the Olfactory Groove to the Mesial Temporal Lobe.

Different surgical approaches have been developed to manage lesions of the anterior and middle skull base areas. Frontal, pterional, bifrontal, and fronto-orbito-zygomatic approaches are traditionally used to reach these regions. With advancements in the neurosurgical field, skull opening should be simple and as minimally invasive as possible, tailored on the surgical corridor to the target. The supraorbital approach and the "keyhole" concept have been introduced and popularized by Axel Perneczky starting from 1998 and are now considered a part of everyday practice. The extended possibilities of this surgical route, considering the reachable targets and surgical limits, are described and systematically analyzed, including a description of the salient surgical anatomy, presenting different illustrative cases. Different illustrative cases are presented and discussed to underline the potentials and limits of the minimally invasive subfrontal approach (MISFA) and the possibilities to tailoring the craniotomy on the basis of the targets: extra-axial lesions with different localizations (anterior roof of the orbit, olfactory groove, tuberculum sellae, medial third of the sphenoid wing, anterior and posterior clinoid process), deeper intra-axial lesions (gyrus rectus, medial temporal lobe-uncus-amygdala-anterior hippocampus), and vascular lesions (anterior communicating aneurysm). Each case has been preoperatively planned considering the anatomical and radiologic features and using virtual simulation software to tailor the best possible corridor to reach the surgical target. The MISFA is a safe multicorridor approach that can be used efficiently to manage lesions of the anterior and middle skull base areas with extremely low approach-related morbidity.

Combined Nasal Endoscopic and Subfrontal Craniotomy for Resection Tumors of Anterior Skull Base.

Sinonasal tumors invading anterior skull base is difficult to treat in Otorhinolaryngology and Neurosurgery. Treatment requires the collaboration of ear, nose and throat (ENT) and neurosurgeon to remove the tumor completely. This study was to evaluate the outcome of combined technique nasal endoscopic and subfrontal approach in case of sinonasal tumors involving anterior skull base. Retrospective cross-sectional study. The study was a cross-sectional study that had taken place at Otorhinolaryngology and Neurosurgery Department of Cho Ray Hospital, Vietnam. All 45 patients were enrolled and underwent the surgery. 71.1% of these cases were malignant tumors. The ratio of sinonasal malignant tumor is squamous cell carcinoma and esthesioneuroblastoma were 24.4% and 11.1%, respectively. All the cases were diagnosed as sinonasal tumor invading anterior skull base and successfully removed by combining nasal endoscopic approach with subfrontal craniotomy. The combined nasal endoscopic with subfrontal craniotomy for resection nasoethmoid tumor invading the brain show a good result. This technique is an important adjunct that contribute to the treatment of anterior skull base tumor involving the brain.