Skull Base and Craniofacial Approaches to Minimize Approach-Related Morbidity for Intracerebral Complex Neoplastic and Vascular Lesions

Introduction: Skull base is often defined a “no man's land,” often requiring a multidisciplinary approach between neurosurgeons, head and neck surgeons, interventional neuroradiologists, radio/chemotherapists, and other professionals. Despite the development of lesser invasive endoscopic and microscopic techniques, traditional open approaches continue to be the cornerstone strategy in the resection of skull base neoplastic or vascular lesions. In the recent years, we have applied the skull base approach philosophy for intracerebral lesions to minimize the approach-related complications.

Methods: All clinical and radiological data regarding patients surgically treated for skull base vascular or neoplastic lesions in six years were collected. All patients were pre- and postoperatively stratified by clinical and radiological assessment. Minimum and maximum follow-up ranged from 6 to 48 months.

Results: From January 2015 to January 2021, twenty-two patients were surgically treated as follows: (1) one Le Fort I transmaxillary transclival approach for an AICA aneurysm associated with a posterior fossa AVM; (2) five far-lateral approaches for brain stem cavernous angiomas and foramen magnum intradural meningiomas; (3) five subtemporal transpetrosal (sec. Kawase) approaches for posterior fossa AVM associated with a pontine artery aneurysm and AICA aneurysms; (4) two posterior transpetrosal approaches for brainstem glioma; (5) three endoscopic endonasal approach for a brainstem glioma and a cavernous malformation; (6) five supraorbital keyhole approaches, alone or endoscope-assisted, for tuberculum sellae meningiomas and craniopharyngiomas; (7) one transmandibular transcervical approach for intradural chordoma. Six patients had postoperative complications; three had CSF leakage, either conservatively or surgically treated; one had transitory VI nerve palsy; and two had wound infections.

Conclusion: Even in the minimally invasive approaches and endoscopic era, several open craniofacial approaches, alone or endoscope-assisted, are a valid option to deal with intracerebral lesions. With such various armamentarium of surgical techniques, tailoring the most suitable approach is of paramount importance, and a multidisciplinary strategy can provide a perfect alchemy for new unexplored surgical indications. No approaches are fancy or obsolete when the goal is to reduce the manipulation on surrounding healthy tissues.

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Artikel online veröffentlicht:
15. Februar 2022