Supratotal Resection of Residual Clival Chordoma With Combined Endoscopic Endonasal and Contralateral Transmaxillary Approaches: 2-Dimensional Operative Video

2018 ◽  
Vol 16 (3) ◽  
pp. E88-E89 ◽  
Author(s):  
Philippe Lavigne ◽  
Eric W Wang ◽  
Juan C Fernandez-Miranda
Keyword(s):  
Skull Base ◽  
Surgical Resection ◽  
Abducens Nerve ◽  
Surgical Anatomy ◽  
Petrous Apex ◽  
Complication Rates ◽  
Curative Intent ◽  
Endoscopic Endonasal ◽  
Clival Chordoma ◽  
Supratotal Resection

Abstract The optimal treatment for skull base chordomas is gross total resection followed by radiotherapy and not radiation of partially resected tumors. Supratotal resection, defined as removal beyond all involved bone and dura, is ideal but difficult to achieve.  In this video, we present the case of a 37-yr-old man with new onset of progressive cranial nerve sixth palsy and a skull base lesion compatible with clival chordoma. He underwent partial surgical resection at an outside institution via transcranial approach, with significant tumor residual at the clivus, dorsum sella, posterior clinoids, and petrous apex, extensive dural invasion, and intradural extension with attachment to the basilar artery and its long perforating branches.  Supratotal surgical resection was achieved using an endoscopic endonasal transclival approach, ipsilateral transpteryoid approach to the foramen lacerum for carotid artery mobilization, bilateral interdural transcavernous approach with posterior clinoidectomies, and con-tralateral transmaxillary approach to the petrous apex. Reconstruction was performed in a multilayer fashion with fascia lata and fat grafts, extended nasoseptal flap, a lumbar drainage for 3 d. No cerebrospinal fluid leak occurred, and the abducens nerve palsy significantly improved at 3-mo follow-up. Proton therapy is planned.  Recent advances in endoscopic endonasal surgery allow for very high rates of complete and even supratotal resection despite the challenging location. A long learning curve to acquire the technical skills and complex surgical anatomy is required to decrease complication rates and achieve maximal resection in chordomas. Reoperations are more challenging and risky; therefore, first attempt should have curative intent.  The patient signed informed consent including the use of photographic and video material for educational or academic purposes

scholarly journals Primary Skull Base Chondrosarcomas: A Systematic Review

Cancers ◽  
2021 ◽  
Vol 13 (23) ◽  
pp. 5960
Author(s):  
Paolo Palmisciano ◽  
Ali S. Haider ◽  
Mohammadmahdi Sabahi ◽  
Chibueze D. Nwagwu ◽  
Othman Bin Alamer ◽  
...  
Keyword(s):  
Skull Base ◽  
Surgical Resection ◽  
Management Strategies ◽  
Survival Rates ◽  
Progression Free Survival ◽  
Surgical Approaches ◽  
Symptom Improvement ◽  
Tumor Control ◽  
Complication Rates ◽  
Endoscopic Endonasal

Background: Primary skull base chondrosarcomas (SBCs) can severely affect patients’ quality of life. Surgical-resection and radiotherapy are feasible but may cause debilitating complications. We systematically reviewed the literature on primary SBCs. Methods: PubMed, EMBASE, Scopus, Web-of-Science, and Cochrane were searched following the PRISMA guidelines to include studies of patients with primary SBCs. Clinical characteristics, management strategies, and treatment outcomes were analyzed. Results: We included 33 studies comprising 1307 patients. Primary SBCs mostly involved the middle-fossa (72.7%), infiltrating the cavernous-sinus in 42.4% of patients. Cranial-neuropathies were reported in 810 patients (62%). Surgical-resection (93.3%) was preferred over biopsy (6.6%). The most frequent open surgical approaches were frontotemporal-orbitozygomatic (17.6%) and pterional (11.9%), and 111 patients (21.3%) underwent endoscopic-endonasal resection. Post-surgical cerebrospinal-fluid leaks occurred in 36 patients (6.5%). Radiotherapy was delivered in 1018 patients (77.9%): photon-based (41.4%), proton-based (64.2%), and carbon-based (13.1%). Severe post-radiotherapy complications, mostly hypopituitarism (15.4%) and hearing loss (7.1%) were experienced by 251 patients (30.7%). Post-treatment symptom-improvement (46.7%) and reduced/stable tumor volumes (85.4%) showed no differences based on radiotherapy-protocols (p = 0.165; p = 0.062). Median follow-up was 67-months (range, 0.1–376). SBCs recurrences were reported in 211 cases (16.1%). The 5-year and 10-year progression-free survival rates were 84.3% and 67.4%, and overall survival rates were 94% and 84%. Conclusion: Surgical-resection and radiotherapy are effective treatments in primary SBCs, with acceptable complication rates and favorable local tumor control.

scholarly journals Recurrent Chordoma Resection in the Advanced Multimodality Image Guided Operating Suite: 2-Dimensional Operative Video

2021 ◽  
Vol 20 (5) ◽  
pp. E344-E345
Author(s):  
Walid Ibn Essayed ◽  
Kaith K Almefty ◽  
Ossama Al-Mefty
Keyword(s):  
Skull Base ◽  
Surgical Resection ◽  
Petrous Apex ◽  
Tumor Control ◽  
Image Guided ◽  
Endoscopy Ultrasound ◽  
Radiation Induced ◽  
Multimodality Image ◽  
The Right ◽  
Operating Suite

Abstract Recurrent skull base chordomas are challenging lesions. They already had maximum radiation, and in the absence of any effective medical treatment, surgical resection is the only treatment.1,2 Surgery on recurrent previously radiated chordomas, however, carries much higher risk and the likelihood of subtotal resection. Maximizing tumor resection allows longer tumor control.3-5 The Advanced Multimodality Image Guided Operating Suite developed at the Brigham and Women's Hospital, Harvard Medical School, with the support of the National Institutes of Health, provides an optimal environment to manage these tumors. It offers the capability to obtain and integrate multiple modalities during surgery, including magnetic resonance imaging (MRI), positron emission tomography-computed tomography (PET-CT), endoscopy, ultrasound, fluoroscopy, and the ability to perform emergent endovascular procedures.5-7 The patient is a 39-yr-old male, presenting after 19 yr follow-up of a surgical resection and proton beam treatment for a skull base chordoma. He developed progressive ophthalmoplegia due to recurrence of his chordoma at the right petrous apex and cavernous sinus. Preoperative angiography demonstrated narrowing of the petrous segment of the right carotid artery suspect of radiation-induced angiopathy. The presence of radiation-induced angiopathy increases the risk of intraoperative carotid rupture, and the availability of endovascular intervention in the operative suite added favorable preparedness to deal with such complications if they happen. Given the clinical and radiological progression, surgical intervention was carried out through the prior zygomatic approach with the goal of performing maximum resection.8 The patient had an uneventful postoperative course and remained stable until he had a second recurrence 4 yr later. The patient consented to the procedure.

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Endoscopic Endonasal Approach to the Orbit

2021 ◽  
Author(s):  
Laura Salgado-Lopez ◽  
Luciano C. Leonel ◽  
Michael Obrien ◽  
Adedamola Adepoju ◽  
Michael J. Link ◽  
...  
Keyword(s):  
Skull Base ◽  
Surgical Anatomy ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal

Surgical nuances for the endoscopic endonasal transpterygoid approach to lateral sphenoid sinus encephaloceles

2012 ◽  
Vol 32 (6) ◽  
pp. E5 ◽  
Author(s):  
Richard F. Schmidt ◽  
Osamah J. Choudhry ◽  
Joseph Raviv ◽  
Soly Baredes ◽  
Roy R. Casiano ◽  
...  
Keyword(s):  
Skull Base ◽  
Sphenoid Sinus ◽  
Skull Base Surgery ◽  
Surgical Anatomy ◽  
Endoscopic Endonasal ◽  
Csf Rhinorrhea ◽  
Lateral Recess ◽  
Sternberg Canal ◽  
Deep Location ◽  
Repair Techniques

Lateral sphenoid encephaloceles of the Sternberg canal are rare entities and usually present with spontaneous CSF rhinorrhea. Traditionally, these were treated via transcranial approaches, which can be challenging given the deep location of these lesions. However, with advancements in endoscopic skull base surgery, including improved surgical exposures, angled endoscopes and instruments, and novel repair techniques, these encephaloceles can be resected and successfully repaired with purely endoscopic endonasal approaches. In this report, the authors review the endoscopic endonasal transpterygoid approach to the lateral recess of the sphenoid sinus for repair of temporal lobe encephaloceles, including an overview of the surgical anatomy from an endoscopic perspective, and describe the technical operative nuances and surgical pearls for these cases. The authors also present 4 new cases of lateral sphenoid recess encephaloceles that were successfully treated using this approach.

scholarly journals Endoscopic endonasal surgical management of chondrosarcomas with cerebellopontine angle extension

2014 ◽  
Vol 37 (4) ◽  
pp. E13 ◽  
Author(s):  
Paulo M. Mesquita Filho ◽  
Leo F. S. Ditzel Filho ◽  
Daniel M. Prevedello ◽  
Cristian A. N. Martinez ◽  
Mariano E. Fiore ◽  
...  
Keyword(s):  
Skull Base ◽  
Posterior Fossa ◽  
Cerebellopontine Angle ◽  
Tumor Resection ◽  
Petrous Bone ◽  
Petrous Apex ◽  
Total Resection ◽  
Endoscopic Endonasal ◽  
Female Ratio ◽  
Male Female Ratio

Object Skull base chondrosarcomas are slow-growing, locally invasive tumors that arise from the petroclival synchondrosis. These characteristics allow them to erode the clivus and petrous bone and slowly compress the contents of the posterior fossa progressively until the patient becomes symptomatic, typically from cranial neuropathies. Given the site of their genesis, surrounded by the petrous apex and the clival recess, these tumors can project to the middle fossa, cervical area, and posteriorly, toward the cerebellopontine angle (CPA). Expanded endoscopic endonasal approaches are versatile techniques that grant access to the petroclival synchondrosis, the core of these lesions. The ability to access multiple compartments, remove infiltrated bone, and achieve tumor resection without the need for neural retraction makes these techniques particularly appealing in the management of these complex lesions. Methods Analysis of the authors’ database yielded 19 cases of skull base chondrosarcomas; among these were 5 cases with predominant CPA involvement. The electronic medical records of the 5 patients were retrospectively reviewed for age, sex, presentation, pre- and postoperative imaging, surgical technique, pathology, and follow-up. These cases were used to illustrate the surgical nuances involved in the endonasal resection of CPA chondrosarcomas. Results The male/female ratio was 1:4, and the patients’ mean age was 55.2 ±11.2 years. All cases involved petrous bone and apex, with variable extensions to the posterior fossa and parapharyngeal space. The main clinical scenario was cranial nerve (CN) palsy, evidenced by diplopia (20%), ptosis (20%), CN VI palsy (20%), dysphagia (40%), impaired phonation (40%), hearing loss (20%), tinnitus (20%), and vertigo/dizziness (40%). Gross-total resection of the CPA component of the tumor was achieved in 4 cases (80%); near-total resection of the CPA component was performed in 1 case (20%). Two patients (40%) harbored high-grade chondrosarcomas. No patient experienced worsening neurological symptoms postoperatively. In 2 cases (40%), the symptoms were completely normalized after surgery. Conclusions Expanded endoscopic endonasal approaches appear to be safe and effective in the resection of select skull base chondrosarcomas; those with predominant CPA involvement seem particularly amenable to resection through this technique. Further studies with larger cohorts are necessary to test these preliminary impressions and to compare their effectiveness with the results obtained with open approaches.

scholarly journals Surgical Anatomy for the Endoscopic Endonasal Approach to the Ventrolateral Skull Base

2017 ◽  
Vol 57 (10) ◽  
pp. 534-541 ◽  
Author(s):  
Kenichi OYAMA ◽  
Shigeyuki TAHARA ◽  
Toshio HIROHATA ◽  
Yudo ISHII ◽  
Daniel M PREVEDELLO ◽  
...  
Keyword(s):  
Skull Base ◽  
Surgical Anatomy ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal

scholarly journals Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa

2005 ◽  
Vol 19 (1) ◽  
pp. 1-10 ◽  
Author(s):  
Amin B. Kassam ◽  
Paul Gardner ◽  
Carl Snyderman ◽  
Arlan Mintz ◽  
Ricardo Carrau
Keyword(s):  
Skull Base ◽  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Surgical Anatomy ◽  
Illustrative Case ◽  
Endonasal Approach ◽  
Transnasal Approach ◽  
Endoscopic Endonasal ◽  
Expanded Endonasal Approach ◽  
Neurovascular Structures

Object The middle third of the clivus and the region around the petrous internal carotid artery (ICA) is a difficult area of the skull base in terms of access. This is a deep area rich with critical neurovascular structures, which is often host to typical skull base diseases. Expanded endoscopic endonasal approaches offer a potential option for accessing this difficult region. The objective of this paper was to establish the clinical feasibility of gaining access to the paraclival space in the region of the middle third of the clivus, to provide a practical modular and clinically applicable classification, and to describe the relevant critical surgical anatomy for each module. Methods The anatomical organization of the region around the petrous ICA, cavernous sinus, and middle clivus is presented, with approaches divided into zones. In an accompanying paper in this issue by Cavallo, et al., the anatomy of the pterygopalatine fossa is presented; this was observed through cadaveric dissection for which an expanded endonasal approach was used. In the current paper the authors translate the aforementioned anatomical study to provide a clinically applicable categorization of the endonasal approach to the region around the petrous ICA. A series of zones inferior and superior to the petrous ICA are described, with an illustrative case presented for each region. Conclusions The expanded endonasal approach is a feasible approach to the middle third of the clivus, petrous ICA, cavernous sinus, and medial infratemporal fossa in cases in which the lesion is located centrally, with neurovascular structures displaced laterally.

Comparative analysis of the anterior transpetrosal approach with the endoscopic endonasal approach to the petroclival region

2016 ◽  
Vol 125 (5) ◽  
pp. 1171-1186 ◽  
Author(s):  
Jun Muto ◽  
Daniel M. Prevedello ◽  
Leo F. S. Ditzel Filho ◽  
Ing Ping Tang ◽  
Kenichi Oyama ◽  
...  
Keyword(s):  
Abducens Nerve ◽  
Direct Access ◽  
Petrous Apex ◽  
Horizontal Line ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Petroclival Region ◽  
Advantages And Disadvantages ◽  
Anterior Transpetrosal Approach

OBJECTIVE The endoscopic endonasal approach (EEA) offers direct access to midline skull base lesions, and the anterior transpetrosal approach (ATPA) stands out as a method for granting entry into the upper and middle clival areas. This study evaluated the feasibility of performing EEA for tumors located in the petroclival region in comparison with ATPA. METHODS On 8 embalmed cadaver heads, EEA to the petroclival region was performed utilizing a 4-mm endoscope with either 0° or 30° lenses, and an ATPA was performed under microscopic visualization. A comparison was executed based on measurements of 5 heads (10 sides). Case illustrations were utilized to demonstrate the advantages and disadvantages of EEA and ATPA when dealing with petroclival conditions. RESULTS Extradurally, EEA allows direct access to the medial petrous apex, which is limited by the petrous and paraclival internal carotid artery (ICA) segments laterally. The ATPA offers direct access to the petrous apex, which is blocked by the petrous ICA and abducens nerve inferiorly. Intradurally, the EEA allows a direct view of the areas medial to the cisternal segment of cranial nerve VI with limited lateral exposure. ATPA offers excellent access to the cistern between cranial nerves III and VIII. The quantitative analysis demonstrated that the EEA corridor could be expanded laterally with an angled drill up to 1.8 times wider than the bone window between both paraclival ICA segments. CONCLUSIONS The midline, horizontal line of the petrous ICA segment, paraclival ICA segment, and the abducens nerve are the main landmarks used to decide which approach to the petroclival region to select. The EEA is superior to the ATPA for accessing lesions medial or caudal to the abducens nerve, such as chordomas, chondrosarcomas, and midclival meningiomas. The ATPA is superior to lesions located posterior and/or lateral to the paraclival ICA segment and lesions with extension to the middle fossa and/or infratemporal fossa. The EEA and ATPA are complementary and can be used independently or in combination with each other in order to approach complex petroclival lesions.

scholarly journals Contralateral Transmaxillary Approach for Resection of Chondrosarcoma of the Petrous Apex: A Case Report

2021 ◽  
pp. 014556132098216
Author(s):  
Jesse D. Lawrence ◽  
Robert Marsh ◽  
Meghan T. Turner
Keyword(s):  
Abducens Nerve ◽  
Petrous Apex ◽  
Lytic Lesion ◽  
Adjuvant Radiation ◽  
Low Grade ◽  
Endoscopic Endonasal ◽  
Postoperative Mri ◽  
Novel Approach ◽  
Magnetic Resonance Imaging Mri

Background: Deep location and neurovascular structures make access to lesions of the petrous apex a significant challenge. A novel approach for these tumors is the contralateral transmaxillary approach. Clinical Presentation: A 31-year-old male was evaluated for left abducens nerve palsy. Magnetic resonance imaging (MRI) and computed tomography revealed an enhancing, lytic lesion of the petrous apex with extension to the cavernous sinus and petroclival junction. The patient underwent a combined endoscopic contralateral transmaxillary and endoscopic endonasal transclival approach for resection of the lesion. No new or worsening neurologic deficits were noted following the procedure. Pathology revealed low-grade chondrosarcoma (grade I). Postoperative MRI revealed gross total resection of the lesion. Patient underwent adjuvant radiation therapy at the discretion of radiation oncology. Conclusion: The contralateral transmaxillary approach to the petrous apex allows for resection of lesions of the petrous apex with the ability to extend the dissection laterally. Excellent results achieved by institutions with advanced extended endoscopic endonasal experience can be reproduced in institutions with less experience. Further characterization of the risks and benefits of this approach is needed.

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