Search Results (71)

Background: Endonasal endoscopic approaches to the skull base are still under investigation, with research aiming to achieve minimally invasive procedures that maximize resection while minimizing complications. This study shares our experience with a mononostril technique and compares it with the existing literature on mononostril approaches for sellar lesions. Methods: A systematic review of eight large series, totaling 1520 patients who underwent endoscopic mononostril transsphenoidal surgery, was performed. The surgical technique was detailed, and parameters such as resection completeness, operative time, complications, and nasal symptoms were analyzed. Results: Gross total resection ranged from 56% to 100% for non-functioning adenomas, 54% to 89% for hormone-secreting adenomas, and 83% to 100% for other sellar lesions. The most common complications were CSF leaks (1.5–4.1%) and nasal issues, such as epistaxis or sinusitis (0–6%). Internal carotid artery injury occurred in 0–1% of cases. The average surgical duration was 87 to 168 min. Conclusions: The mononostril approach offers comparable resection rates, CSF leak risks, and morbidity to binostril or microsurgical methods. The mononostril approach is fast, minimally invasive, and preserves the nasal mucosa, making it a viable option for many sellar lesions. Full article

Objective: Craniopharyngioma recurrence risk studies comparing gross total resection (GTR) vs. subtotal resection (STR) with radiotherapy (XRT) provide inconclusive or contradictory results. This may be an effect of the small group sizes and diversity in the approaches used. Currently, the endoscopic endonasal approach (EEA) is preferred in craniopharyngioma management. Here, we aimed to perform a meta-analysis comparing recurrence risk after GTR vs. STR plus XRT in patients treated with the EEA regimen. Methods: We performed a systematic literature search of original English language papers on craniopharyngioma management published in the PubMed, Web of Science, and Scopus databases up to 18 October 2023. Eleven articles included data on recurrence rate after EEA: GTR vs. STR with XRT. We extracted the year of publication, number of patients, surgical approach, extent of resection, and follow-up duration. We used meta-analysis for the odds ratio (OR) in fixed and random effects models and Egger’s and Begg’s tests to assess heterogeneity and publication bias. Follow-up duration and time to recurrence were additionally included in Kaplan–Meier curves with log-rank test analysis. Results: We observed a lower recurrence rate in patients after GTR (10%) as compared to STR with XRT (30%), OR = 0.299, p < 0.001. To increase data reliability, we limited our analysis to studies with at least five patients in each subgroup and also observed lower recurrence in patients after GTR (12%) as compared to STR with XRT (27%), OR = 0.376, p = 0.011. Survival analysis confirmed significant differences in recurrence-free survival percentages between these groups (p = 0.008). Conclusions: To date, this is the largest meta-analysis evaluating the recurrence risk in patients undergoing EEA for craniopharyngioma resection, comparing outcomes between those treated with GTR and those treated with STR plus XRT. The results suggest that GTR significantly reduces recurrence risk. Full article

Background/Objectives: Although endoscopic dacryocystorhinostomy (DCR) has been widely accepted as the procedure of choice for nasolacrimal duct obstruction (NLDO) management due to most etiologies, concerns regarding the reactivation of disease and involvement of surrounding structures add to hesitation in its utilization for granulomatosis with polyangiitis (GPA) patients. No study has directly compared outcomes of external vs. endoscopic DCR in GPA patients. This information can be helpful for patient counselling and choosing a personalized surgical approach for the best results. Methods: A scoping review of the literature was performed in January 2024. The following databases were searched using a combination of MeSH (Medical Subject Headings) and keywords: Ovid MEDLINE, Ovid EMBASE, Scopus, and Web of Science. This scoping review is not registered. Medical records of two GPA patients who underwent endoscopic DCR at our center were reviewed. Results: The search yielded 96 articles; 15 articles met the inclusion criteria for a full review. Six studies with 22 procedures reported 100% success with endoscopic DCR. Nine studies with 122 procedures reported success in 88.5% of cases with external DCRs. Additional perioperative immunosuppression was recommended in patients with severe mucosal inflammation. The case series presents the disease course, details of surgery, and perioperative management in two GPA patients with NLDO who underwent endoscopic DCR successfully. Conclusions: Endoscopic DCR was associated with equivalent or better success rates and lower complications compared to external DCR in GPA patients. Ensuring disease remission state and appropriate immunomodulatory therapy can help prevent the proposed risk of endonasal disease reactivation with endoscopic DCR. Full article

Background/Objectives: The surgical management of trigeminal schwannomas (TSs) has evolved considerably, with increasing interest in minimally invasive approaches. We performed a meta-regression analysis to characterise temporal trends in surgical strategies for TS and to explore factors influencing outcomes. Methods: This systematic review and meta-regression followed the PRISMA 2020 guidelines. Comparative studies published in English reporting surgical treatment of TS were included. Outcomes assessed were the extent of resection (EOR), improvement or worsening of trigeminal symptoms, and postoperative complications. Meta-analyses of pooled frequencies were performed, and meta-regression analyses evaluated associations between surgical approach, tumour localization, year of publication, and outcomes. Surgical approaches were categorized as microsurgical antero-lateral (M-AL-Apr), retrosigmoid (RSA), endoscopic endonasal (EEA), and endoscopic transorbital (ETOA). Tumour localization was stratified using the Samii classification. Results: Fifteen studies (583 surgeries) were included. Endoscopic approaches accounted for 20.1% of cases, with increasing use over time (β = 0.12—p < 0.001), largely driven by transorbital access for Samii type A and C tumours. The use of M-AL-Apr declined. The pooled gross-total resection (GTR) rate was 73% (I² = 78.8%). The stratified meta-regression identified a temporal decrease in GTR for Samii type C tumours alone, while resection rates for types A, B, and D remained stable, likely reflecting the increasing proportion of anatomically complex cases in recent series Trigeminal impairment improved postoperatively in 17% (I² = 84.5%), while worsening of trigeminal symptoms was rare (β = 0.07%—I² = 0%). Complication rates were 11.6% (I² = 32.7%) but with a temporal increase (β = 0.041, p = 0.047). Tumour type was the dominant predictor of EOR, functional outcomes, and complications. Conclusions: Surgical management of TS has evolved towards minimally invasive techniques, particularly endoscopic routes, reflecting advances in technology and a focus on functional preservation. Tumour anatomy remains the key determinant of surgical outcomes, highlighting the importance of tailored, anatomy-driven surgical planning. Full article

Background/Objectives: Giant pituitary adenomas (GPAs) pose significant surgical challenges due to their large size, parasellar/suprasellar extensions, and proximity to critical neurovascular structures. Although the endoscopic endonasal approach (EEA) is preferred for pituitary tumors, achieving gross total resection (GTR) in GPAs remains difficult. Additional transcranial approaches may improve resection rates while minimizing morbidity. This study evaluates the impact of endoscopic and combined surgical approaches on resection outcomes using a classification system previously defined in GPA patients treated over the past year. Methods: Among 517 pituitary adenomas treated in our clinic between September 2023 and September 2024, 49 GPA patients underwent endoscopic endonasal, transcranial, or combined surgery. Their medical records and surgical videos were retrospectively reviewed. Data included demographics, symptoms, imaging, surgical details, and follow-up outcomes. Tumor resection rates were analyzed based on the “landmark-based classification”, considering radiological and pathological features and surgical approach. Results: The mean age was 45.5 years (female/male: 14/35). Zone distribution was 8 (Zone 1), 21 (Zone 2), and 20 (Zone 3). GTR was achieved in 34.6%, near-total resection in 36.7%, and subtotal resection in 28.5%. Endoscopic surgery was performed in 41 patients, combined surgery in 7, and a transcranial approach in 1. Complications included diabetes insipidus (9/49), cerebrospinal fluid leakage (2/49), apoplexy (2/49), hypocortisolism (3/49), epidural hematoma (1/49), and epistaxis (1/49). Conclusions: While EEA is effective for Zone 1 and 2 GPAs, Zone 3 tumors often require combined or transcranial approaches for better resection. A multimodal strategy optimizes tumor removal while minimizing morbidity. Individualized surgical planning based on tumor classification is crucial for improving outcomes. Full article

Background: Naso-ethmoidal schwannoma is a rare slow-growing tumor arising from the Schwann cells of the sinonasal tract. This study discusses the evolution of surgical approaches to naso-ethmoidal schwannomas with respect to tumor growth and recent advances in minimally invasive techniques. Materials and Methods: A comprehensive literature review on Embase online electronic database on benign naso-ethmoidal schwannoma was performed. Demographic, clinical, neuroradiological, pathological, and surgical factors were analyzed and discussed. Results: Twenty-five cases met the inclusion criteria. No predilection for gender was evident. The mean age at diagnosis was 40.2 years old. Nasal obstruction was the most common presenting symptom (64%), followed by headache (60%), hypo-anosmia (24%), and visual impairment (24%). Skull base and orbital involvement were registered in 64% and 16% of cases, respectively. Surgery is the unique curative treatment, with the endoscopic endonasal approach which plays the leading role (44%). Gross total resection was possible in all cases and was associated with no recurrence. The perioperative complication rate was 32% and mainly consisted of cerebrospinal fluid leakage. The mean time for treatment was 21 months. All patients were alive at last follow up. Conclusion: Surgery is the only curative treatment for naso-ethmoidal schwannomas, with the main goal to relief clinical manifestations. The endoscopic endonasal route represents the master approach for lesions confined to the midline. Transcranial and transorbital approaches play a complementary role when large intracranial extension and orbital involvement occur, respectively. Full article

Background/Objectives: Spindle cell oncocytomas (SCOs) of the pituitary gland are rare tumors often misdiagnosed for nonfunctioning pituitary macroadenomas. Although classified as grade 1, they are often challenging in terms of diagnosis and treatment. Pituitary SCOs harbor peculiar features such as hypervascularity and stronger adherence to surrounding structures, with increased risk of hemorrhage, partial resection, and significantly higher recurrence rate. Almost 100 cases have been reported so far. The role of surgery is still crucial for the decompression of the optic chiasm as well as for achieving diagnosis. However, given the higher tendency of recurrence, the role of postoperative radiotherapy has been investigated over the last few years. Case presentation: Here, we reported a case of a 48-year-old female with a pituitary SCO treated at our institution, in which we focused on diagnosis, treatment, and follow-up. Conclusions: This type of tumor presents a challenge related to its higher vascularity and strong adherence to the surrounding structures. Adjuvant radiotherapy is something that should be considered, especially when gross total resection is not achieved, and finally, SCOs require diligent follow-up to monitor for any signs of disease recurrence or progression. Full article

This review aims to explore the evolution, techniques, and outcomes of minimally invasive spine surgery (MISS) within the field of neurosurgery. We sought to address the increasing burden of spine degeneration in a rapidly aging population and the need for optimizing surgical management. This review explores various techniques in MISS, drawing upon evidence from retrospective studies, case series, systematic reviews, and technological advancements in neurosurgical spine treatment. Various approaches, including endonasal cervical, transoral cervical, transcervical, mini-open/percutaneous, tubular, and endoscopic techniques, provide alternatives for current approaches to a range of spinal pathologies. The main findings of this review highlight potential advantages of MISS over traditional open surgery, including reduced complications, shorter hospital stays, and improved patient outcomes. Our research underscores the importance of adopting MISS techniques to optimize patient care in neurosurgical spine treatment. Full article

Background/Objectives: To evaluate the outcomes of anterior skull base (ASB) reconstruction using single versus double vascularized flap techniques following multiportal cranio-endoscopic approaches (CEA), based on a 12-year experience. Methods: A retrospective analysis was conducted on 46 patients who underwent ASB reconstruction after a CEA at our department between 2010 and 2022. Patients were divided into two groups: Group 1 received a pericranial flap (PF) reinforced with a fascia graft, while Group 2 underwent multiple flap reconstruction with PF, fascia graft, and nasoseptal flap (NSF). The primary outcome measured was the incidence of cerebrospinal fluid (CSF) leakage and the impact of adjuvant radiotherapy (RT) on reconstruction. Results: Group 1 (86.9%) demonstrated no significant postoperative CSF leaks, showing that the PF, combined with multilayer techniques (including underlay sealing matrix and overlay fascia graft), effectively repaired ASB defects. Group 2 (13.1%), employing both PF and NSF, showed similar outcomes, with the dual flap approach particularly beneficial in cases of post-traumatic fistulas or when the nasal septum was spared by disease. No significant differences were observed in complications or flap necrosis, even in patients receiving adjuvant RT. Conclusions: The PF is a reliable and versatile option for ASB reconstruction, often sufficient as a single-flap technique. The addition of an NSF can be beneficial in specific cases, particularly in post-traumatic conditions or tumors with unilateral endonasal invasion. However, PF alone, when combined with a multilayer approach, minimizes the risk of CSF leakage and long-term flap necrosis, underscoring the importance of tailored surgical strategies for optimal outcomes. Full article

Background: This study aims to compare the surgical outcomes of transorbital versus endonasal endoscopic approaches for orbital subperiosteal abscess drainage. Methods: A retrospective review was conducted at a single institution of patients who underwent orbital subperiosteal abscess drainage from November 2009 to April 2023. Results: Of 64 patients, 44 (68.8%) underwent abscess drainage via an orbital approach, while 20 (31.3%) underwent endonasal endoscopic drainage. No significant difference in operative time or visual acuity improvement was found between the two groups. Abscess drainage via orbitotomy was associated with a longer total (average 8.1 days) and postoperative (average 7.3 days) hospitalization time compared to the endoscopic group (average 5.4 days and 4.2 days, respectively), though this difference was not statistically significant (p = 0.197, 0.136, respectively). For medial orbital abscesses, the average length of total and postoperative hospitalization was greater after orbitotomy (p = 0.028 and 0.019, respectively). At discharge, patients who underwent orbitotomy more commonly reported periorbital swelling (p = 0.0003), while postoperative pain was more common in the endoscopic drainage group (p = 0.009). Reoperation rate was higher after orbitotomy (34.1%) compared to the endoscopic drainage group (15.0%), though this was not statistically significant (p = 0.115). Conclusions: Transorbital and endoscopic surgical approaches for orbital abscess drainage have similar surgical outcomes, with no statistically significant differences noted in terms of visual acuity change or reoperation rate. Longer hospital stays were found for patients with medial orbital abscesses drained via orbitotomy. Full article

Background: Biphenotypic sinonasal sarcoma (BSNS) is a low-grade tumor of the sinonasal tract with frequent extension to the orbit and skull base. Due to its rare incidence and recent histopathological and molecular characterization, little data are available in regard to its natural history, treatment and surveillance protocol. Methods: A comprehensive literature review in Embase online electronic databases on BSNS was made. The analyzed factors included the patients’ sex and age, presenting symptoms and signs, anatomical origin and pattern of growth of the tumor, immunohistochemical and molecular features, time to treatment, type of treatment, surgical approach, extent of resection, peri- and post-operative complications, adjuvant therapies, clinical outcome, recurrence and overall survival rates. Results: This literature review involved 34 studies for an overall series of 149 cases of BSNS. The female (66.9%) and middle-aged populations (median 54.88 years old) were mainly affected. The most frequent clinical onset was nasal obstruction (81%), followed by facial discomfort (44%), epistaxis (15.5%) and ocular impairment (14.3%). Ethmoid sinus (67.8%) and nasal cavity (45.4%) were the most common anatomical site of tumor origin, while an extension to the orbit and skull base was registered in 28.7% and 24.5% of cases. Surgery was the main treatment, especially in the form of endoscopic endonasal approach (56.9%), and allowed for gross total resection in 79% of cases. The recurrence rate was 26.2%; three cases of tumor-related death were reported. Median follow-up was 4.6 years. Conclusions: Biphenotypic sinonasal sarcoma is a rare and unique tumoral entity in terms of biological and clinical behavior. Based on the current knowledge, surgery plays the leading role in treatment, accounting for gross total tumor resection in most cases, allowing for clinical symptom and sign resolution and presenting a low rate of perioperative complications. The type of approach and the aim of surgery should be assessed case by case according to patient and pathology features and the surgeon’s experience, as well as the aim of the treatment. Further studies including large surgical series and with long follow-up are required to define prognostic factors and guidelines of treatment for this peculiar pathological entity. Full article

Introduction/Objectives: The endoscopic approach to skull base lesions is widely regarded as less invasive and associated with reduced morbidity, offering favorable outcomes, particularly in terms of short-term quality of life (QOL). However, to date, long-term assessments of both nasal function and tumor-related QOL remain limited. To evaluate patients’ long-term nasal- and tumor-related QOL after endoscopic endonasal resection of pituitary tumors and to detect predictors for poor postoperative QOL. Study Design: This study was a prospective cohort study. Methods: All patients with pituitary adenomas who underwent trans-sphenoidal surgery at Tel Aviv Sourasky Medical Center between 2014 and 2021 were recruited. Recruited patients completed the Anterior Skull Base Disease-Specific QOL (ASBS-Q) questionnaire and the Sinonasal Outcome Test 22 (SNOT-22) questionnaire before surgery and 1, 2, and 3–5 years after surgery. Clinical data were collected and analyzed. Results: The study included 43 patients (18 women). No significant decrease was observed in tumor-related quality of life (QOL) scores, measured by ASBS-Q and SNOT-22, throughout the 5-year follow-up period. SNOT-22 score differences from the preoperative baseline at years 1, 3, and 5 were 0.81 [−4.84–6.58], 3.35 [−4.32–11.02], and 3.73 [−2.22–9.68], respectively, with no statistically significant changes. ASBS-Q scores similarly showed no significant changes over time. Subgroup analyses revealed that tumor characteristics (secreting vs. non-secreting, size), surgical factors (intraoperative cerebrospinal fluid leak, gross tumor resection, use of nasoseptal flap), and endocrine remission did not significantly impact QOL (p > 0.05 for all variables). Conclusions: Our study demonstrated that patients who underwent endoscopic pituitary lesion resection maintained high nasal- and tumor-related quality of life over a 5-year follow-up period. However, given the limitations of our study, further multi-center studies with larger patient populations are warranted to validate these results. Full article

Background: Biphenotypic sinonasal sarcoma is a rare low-grade tumor arising from the sinonasal tract, featuring locally aggressive biological behavior, with a tendency to invade the orbit and skull base. There are no defined guidelines of treatment; thus, the management varies among different institutions. The aim of the present study is to provide a modular system of surgical approaches according to the lesion pattern of growth from a literature review. Materials and Methods: A comprehensive and detailed literature review on the PubMed and Embase online electronic databases on biphenotypic sinonasal sarcoma with orbital invasion was conducted. A personal case exhibiting peculiar features was also added. Demographic (patient’s sex and age), clinical (presenting symptoms and time to treatment), neuroradiological (anatomical origin and pattern of growth), and treatment (type of treatment, surgical approach, extent of resection, peri- and postoperative complications, and adjuvant therapies) data, as well as clinical outcome, recurrence rates, and overall survival, were analyzed. Results: Thirty-one patients harboring biphenotypic sinonasal sarcoma with orbital invasion were identified. Tumors mainly affected female patients (66.7%) and a middle-aged population (median 55.2 years old). Simultaneous skull base involvement occurred in most cases (80.6%). Surgery was performed in all but one case (97%), as unique treatment (59%) or in association with radio—(23.5%) and/or chemotherapy (5.9%/2.9%), allowing for gross total tumor resection in most cases (66.7%). The endoscopic endonasal approach was the most adopted surgical corridor (51.7%). The local recurrence rate was 19.3%, and only two cases of tumor-related mortality occurred. Conclusions: Surgery is the only curative treatment, with the main goal to restore/improve/arrest progression of clinical manifestations. The endoscopic endonasal route represents the master approach for lesions confined to the midline. Microsurgical transcranial and endoscopic transorbital approaches have a complementary role for addressing the lesion’s component with large intracranial extension or affecting the paramedian aspect of the anterior cranial fossa and superior–lateral orbital compartment, respectively. The approach selection should be made case by case according to the tumor pattern of growth. Full article

Background: Pituitary adenomas represent the most common pituitary disorder, with an estimated prevalence as high as 20%, and they can manifest with hormone hypersecretion or deficiency, neurological symptoms from mass effect, or incidental findings on imaging. Transsphenoidal surgery, performed either microscopically or endoscopically, allows for a better extent of resection while minimising the associated risk in comparison to the transcranial approach. Endoscopy allows for better visualisation and improvement in tumour resection with an improved working angle and less nasal morbidity, making it likely to become the preferred surgical treatment for pituitary neoplasms. The learning curve can be aided by telementoring. Methods: We retrospectively analysed the clinical records of 94 patients who underwent an endoscopic endonasal resection of a pituitary neoplasm between the years 2011 and 2023 at Maribor University Medical Centre in Slovenia. Remote surgical telementoring over 3 years assisted with the learning curve. Results: The proportion of complication-free patients significantly increased over the observed period (60% vs. 79%). A gradual but insignificant increase in the percentage of patients with improved endocrine function was observed. Patients’ vision improved significantly over the observed period. By gaining experience, the extent of gross total tumour resection increased insignificantly (67% vs. 79%). Conclusions: Telementoring for the endoscopic endonasal approach to pituitary neoplasms enables low-volume centres to achieve efficiency, decreasing rates of postoperative complications and increasing the extent of tumour resection. Full article

Introduction. Clival chordomas represent a rare but clinically significant subset of skull base tumors, characterized by a locally aggressive nature and a location in proximity to vital neurovascular structures. Surgical resection, often combined with adjuvant therapies, remains the cornerstone of clival chordoma treatment, and various approaches and techniques have evolved to maximize tumor removal while preserving neurological function. Recent advancements in skull base surgery, imaging, and adjuvant therapies have improved outcomes by reducing morbidity and thus enhancing long-term survival. Methods and Results. We have conducted a systematic review on PubMed/Medline following PRISMA guidelines regarding indications, the extent of resection (EOR), and complication rates. Then, we present three illustrative cases from our personal experience, which started 25 years ago with CVJ instrumentation procedures and 15 years ago with anterior decompressive transmucosal procedures performed with the aid of an operative microscope, an endoscope, and neuroradiological monitoring. Conclusions. Traditionally, the transoral approach (TOA) is the most frequently used corridor for accessing the lower clivus and the anterior craniovertebral junction (CVJ), without the need to mobilize or retract neural structures; however, it is associated with a high rate of complications. The endonasal approach (EEA) provides access to the anterior CVJ as well as to the lower, middle, and superior clivus, decreasing airway and swallowing morbidity, preserving palatal function, decreasing postoperative pain, and reducing the incidence of tracheostomy. The submandibular retropharyngeal approach (SRA) allows unique access to certain cervical chordomas, which is better suited when the lesion is located below the clivus and in the midline. Full article