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Sphenoid wing meningiomas (SWMs) can be treated with complete surgical resection and the recently introduced endoscopic transorbital approach (ETOA) offers a minimally invasive alternative. In this study, the surgical outcome of ETOA and the extended mini-pterional approach (eMPTA) for SWMs with osseous involvement is compared. From October 2015 to May 2019, 24 patients underwent surgery for SWMs with osseous involvement. Among them, tumor resection was performed by ETOA for 11 patients (45.8%) and eMPTA for 13 patients (54.2%). The tumor characteristics, surgical outcome and morbidity, and approach-related aesthetic outcome were analyzed and compared retrospectively between ETOA and eMPTA based on SWM classification. The location of SWMs was mostly the middle sphenoid ridge (group III) (45.8%), followed by the greater sphenoid wing (group IV) (29.2%). Simpson resection grades I/II were achieved in 9 of 11 patients (81.8%) with ETOA and 11 of 13 patients (84.6%) with eMPTA. There were no differences in tumor characteristics between the 2 approaches. Surgery time, surgical bleeding, and hospital length of stay were significantly shorter with ETOA. Three patients had transient surgical morbidities such as diplopia (n = 1), ptosis (n = 1), and cerebrospinal fluid leak (n = 1) after ETOA. No differences could be seen in surgical morbidities between ETOA and eMPTA. ETOA can provide direct access to the sphenoid bone and resectability with a more rapid and minimally invasive exposure than does eMPTA. Maximal subtotal resection with extensive sphenoid bone decompression for tumors with cavernous sinus infiltration is the key to a good clinical outcome, regardless of the surgical approach. [ABSTRACT FROM AUTHOR]

Objective Vertebral artery (VA) transposition in the extreme-lateral transcondylar approach can minimize the manipulation of the low cranial nerves and the brain stem. The authors describe the surgical technique of VA transposition. Methods From March 2000 to December 2014, 28 of 48 patients underwent VA transposition for anterior foramen magnum meningioma (16 patients) and craniocervical junction (CCJ) tumors (12 patients). Tumor was resected via an extreme-lateral approach with partial condylectomy to expose the anterior portion of the brain stem. For intradural tumors, the VA was mobilized caudomedially after circumferential dural incision around the VA at the level of the foramen magnum. For extradural tumors involving the CCJ, VA was transposed medially from the transverse foramen of C1 without any dural incision. Results Gross total resection was achieved in 26 of 28 patients (92.9%) with VA transposition. Histologically, meningioma and schwannoma were most common. The origin of the tumors was foramen magnum (57.1%), C1 nerve root (17.9%), clivus (10.7%), jugular foramen (7.1%), posterior skull base (3.6%), and hypoglossal canal (3.6%). VA transposition was performed intradurally in 19 patients (67.9%) and extradurally in 9 patients (32.1%). Surgical morbidity was 17.9% including 4 patients with hypoglossal nerve palsy and 1 patient with quadriparesis. The mean follow-up duration after surgery was 4.2 years (range, 0.1–14.8 years). Conclusions VA transposition can provide a wide surgical window for anterior foramen magnum meningioma or tumors involving the CCJ with the least manipulation of the neuraxis. [ABSTRACT FROM AUTHOR]

Objective Head and neck tumors are a heterogeneous group and often invade the skull base. Various radiation techniques can be used for these tumors when surgery is unavailable. This study investigated the indications for gamma knife radiosurgery (GKRS) in benign head and neck tumors. Methods Thirty-seven lesions in 35 patients were treated with GKRS for schwannoma, juvenile nasal angiofibroma, choroidal hemangioma, and pleomorphic adenoma. The median follow-up period was 43.0 months (range, 12.2–174.1 months). Results Tumor control was achieved in 35 of 37 lesions (94.6%) at last follow-up after GKRS. Thirty-four lesions (91.9%) decreased, 1 lesion (2.7%) remained stable, and 2 lesions (5.4%) increased in size. Clinically, 15 cases (40.5%) showed improvement, 17 cases (45.9%) were stable, 1 case (2.7%) experienced deterioration, and 4 cases (10.8%) developed new symptoms. Four of the 5 cases that exhibited deterioration or new symptoms improved. Conclusions GKRS is a reasonable alternative to surgery that can effectively control tumor growth and preserve functions of the head and neck in primary, residual, or recurrent benign head and neck tumors. [ABSTRACT FROM AUTHOR]

Background Cavernous sinus (CS) invasion is an unfavorable factor hindering the remission of growth hormone (GH)-secreting pituitary adenomas. Little data exist on aggressive surgical resection, however. We investigated the role of CS exploration for GH-secreting pituitary adenomas with CS invasion. Methods We classified 132 patients with GH-secreting pituitary adenomas invading CS into 4 groups. The patients underwent surgery using a microsurgical transsphenoidal approach (TSA) with endoscopic assistance. Adenomas with CS invasion confined to the medial compartment of the internal carotid artery (ICA) were classified as type A (without radiologic evidence) or type B (with radiologic evidence). Adenomas with ICA encasement were classified according to the surgical approach as type C (standard TSA) or type D (far-lateral TSA). Surgical and endocrinologic outcomes were compared across groups. Results For type A, B, C, and D tumors, the rates of gross total resection were 100%, 73.6%, 14.7%, and 0%, respectively, and the rates of endocrinologic remission by surgery alone were 100%, 62.3%, 26.5%, and 0%, respectively. There was no endocrinologic remission by surgery alone for type D tumors; nevertheless, compared with type C tumors, type D tumors showed marked reductions in the postoperative nadir of GH at 1 week, 6 months, and 1 year and of insulin-like growth factor I at 1 year. Conclusions For tumors with CS invasion confined to the medial compartment of the ICA, total resection should be attempted by direct visualization of the entire medial wall of the CS. Even for tumors with ICA encasement, aggressive tumor resection by far-lateral TSA can increase the chance of remission with the help of adjuvant treatment. [ABSTRACT FROM AUTHOR]

In 1985, Kawase published an anterior petrosal approach to expose the posterior cranial fossa and to minimize retraction of the temporal lobe. However, some neurosurgeons still have difficulty with removing tumors through an anterior petrosal approach because a complete understanding of the Kawase pyramid has not been achieved. We hypothesized that if anterior petrosectomy were performed with three-dimensional understanding of the Kawase pyramid, it would have a positive effect on extent of tumor resection. We performed a retrospective study of patients who underwent surgical treatment for meningioma through an anterior petrosal approach. Patients were divided into total resection and subtotal resection groups, and statistical differences between the groups were analyzed. To identify factors predictive of complete tumor removal, univariable and multivariable logistic regression analyses were performed. Width and height of the drilled internal auditory canal of the total resection group were significantly larger than those of the subtotal resection group (P = 0.001, P = 0.033). The operative angle of the total resection group was significantly larger than that of the subtotal resection group (P < 0.001). Regression analyses showed only drilled internal auditory canal width to be predictive of complete tumor removal, increasing the likelihood of complete tumor removal by 2.778-fold with an increase in drilled internal auditory canal width by 1 mm (P = 0.023). Insufficient petrosectomy during an anterior petrosal approach adversely affects the extent of tumor resection. Furthering three-dimensional understanding of the Kawase pyramid could aid in complete tumor resection and better outcomes without causing damage to the surrounding organs. [ABSTRACT FROM AUTHOR]

Background Variations and additions to the endoscopic endonasal exposure have been proposed around a modular strategy. These extensions are often necessary to provide additional working space and reduce conflict between the instruments and the endoscope. Resection of endonasal structures, which affects negatively the sinonasal quality of life, is thus undertaken not only to obtain tumor exposure but also to improve the maneuverability of the instruments. Objective Our objective was to achieve the same skull base exposures and tumor resections and limit the surgical footprint on sinonasal structures and patients' quality of life. Methods Our team developed a surgical technique in which the endoscope and a malleable rotative aspirator are held by the nondominant hand and the other main instrument in the dominant hand. This modification, which we call the chopsticks technique, allows the surgeon to use minimalistic exposures with an improved dynamic perception of the surgical field and reduced conflicts between the instruments. The endonasal structures that are left intact help support the instruments. The same surgical objectives, in terms of exposure and resection, are achieved. We describe our technique and a series of patients operated with this uninarial 3-instruments technique to discuss relevant operative nuances. Conclusions We propose a technical modification that allows the surgeons to benefit from the advantages of a bimanual technique while still holding the endoscope. In our opinion, this technique may improve dynamic understanding of the anatomy and surgical efficiency and reduce the footprint of the surgery. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to identify key anatomic landmarks useful in gaining access to the anteromedial temporal region via the corridor formed by the inferior orbital fissure (IOF), the ophthalmic branch of the trigeminal nerve (V1), and the maxillary branch of the trigeminal nerve (V2) via an endoscopic endonasal approach (EEA). Methods An anatomic dissection of 6 cadaver heads was performed to confirm the feasibility and applicability of an EEA for accessing the anteromedial temporal region. Results After middle turbinectomy, the lateral recess of the sphenoid sinus was opened, the orbital apex was exposed, and the posterior wall of the maxillary sinus was removed, in sequence. The IOF and the pterygopalatine fossa (PPF) were then identified. After opening the foramen rotundum (FR) and removing the bony structure between the FR, V2 was transposed downward. The orbital muscle of Müller was removed. The PPF was mobilized downward exposing the greater wing of the sphenoid bone (GWS). The GWS between V1 and V2 was drilled, therefore exposing the temporal dura. With blunt dissection, the medial temporal dura was peeled away from the cavernous sinus to increase access to the anteromedial temporal region. Conclusions The anteromedial temporal fossa was exposed by drilling the V1-V2 triangle corridor via an EEA. Endoscopic endonasal exposure of the anteromedial temporal fossa is feasible and requires limited endonasal work. This approach may be considered as an alternate surgical corridor to the temporomesial lobe that offers the advantages of a direct route with less temporal lobe retraction. [ABSTRACT FROM AUTHOR]