Concepts in Endoscopic Endonasal Skull Base Surgery:
Choosing the right approach…
Open vs Endoscopic:
Lateral access limited by ICASkeletonization and lateralization of paraclival ICA
Risk of injury to ICA
Transpterygoid infrapetrous approachRisk of injury to Eustachian tube; sacrifice of vidian nerve
Retrosigmoid + EEA + GK
26 yo F with meningioma
Visual deterioration is 2x–5x more frequent in Transcranial than Endonasal approaches *
* Size comparison bias / Goal of surgery
Center # Pts
Preferred Approach GTR GTR
PrimaryGTR
RecurrentCSF leak Meningitis New
CN Recurrence Death/Dz Progression f/up
UPMC 60 EEA 66.7% 82.9% 44% 20% 3.3% 8.3% 33.3% 10% 17.8
Sen et al 2010 65 Lateral
and EEA 58% 64% 47% 21.5% 10.8% ? 49% 33.8% 66
Colli/Al Mefty 2001 53 Lateral 45.3% 44% 31.6% 12.2
% 1.9% 20.6% ? 17% 50
Gay et al 1995 46 Lateral 47% N/A N/A 30% 10% 80% 13% 10.8% 45
Tzortzidis 2006 74 Lateral 71.6% 83% 30% 1.35
% N/A 4% 35% 14.9% 96
Crockard 2001 42 Transoral 4.7% 4% 5.5% 21% 8% 12% ? ? 51
MRI: tumor in right lateral clivus with partial encasement of basilar artery and petrous ICA; extension to foramen rotundum and foramen ovale
Surgery: Endoscopic transclival, right transpterygoid, left transmaxillaryCTM allowed access as far as the parapharyngeal ICA
subtotal resection due to significant lateral extension of tumor
Postop Imaging: near GTR with possible small residual along the left lateral margin of the clivus and jugular bulb (ipsilateral to the transmaxillary approach)
(A)and (B) Preop MRI (C) and (D) Postoperative CT
POST-OPPRE-OP
EEA Open
PreOp
PostOp
porencephalic cave
EEA Open
PreOp
PostOp flair signal changeNeurocognitive function?
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