Fronto - temporal approach in sellar and parasellar tumors

Open access

Abstract

Introduction: The fronto-temporal approach represent the shortest distance to the ipsilateral optic nerve and carotid artery, and allow the direct verification of the optical nerves, the carotid arteries, the pituitary stalk, the tumor and its relationship with the suprasellar structures.

Objective: The purpose of this study is to advocate an available cranial base technique for removing these tumors and to delineate the technique’s advantages that aid in achieving an improved extent of tumor resection and enhancing the patients’ overall outcome.

Materials and methods: We present a retrospective study of a single surgeon experience on 355 consecutive cases with sellar and parasellar tumors admitted and operated by transcranial approaches in our department between January 2000 and December 2012.

Results: Tumors in the sellar region represent 11, 8% of all tumors operated in our department. The most common type of tumor was pituitary adenomas, 165 of cases, followed by sellar and parasellar meningiomas, 128 of cases. Craniopharyngioma represent 12% of cases encountered in this region.

All our cases underwent surgery by transcranial approach, unilateral frontotemporal in 252 of cases (71%). In pituitary adenomas total and near total resection was achieved in 100% of patients operated by transcranial approaches. For resection of craniopharyngiomas we have frequently chosen the extended fronto-temporal approach.

The most common surgical related complications were: postoperative hematomas 9 of cases; wound infections, 6 of cases and CSF leakage, 12 of cases; transient visual alteration in 12 cases, transient third cranial nerve palsy in 6 of cases, transient motor deficit in 7 cases, hydrocephalus, 6 cases; transient diabetes insipidus in the large majority of pituitary adenomas and craniopharingiomas. Only 4 cases of pituitary adenomas and 6 of craniopharingiomas recurred after subtotal resection, requiring re-intervention. The mortality rate in our study was 2%.

Conclusions: Our experience demonstrated that the management of the large suprasellar tumors via fronto-temporal approach remains the main route for these tumors with significant extrasellar extension, fibrous tumors, cases with unrelated pathology that might complicate a transsphenoidal approach and recurrent tumors after previous transsphenoidal surgery. In our opinion there is no need for larger osteotomies or extensive drilling of cranial base. “Instead of bone, remove the tumor; it's easier even for the patient”.

1.Aydin, I. H.; Takçi, E.; Kadioğlu, H. H. et all,: Pitfalls in the Pterional Approach to the Parasellar Area (Review)*min - Minimally Invasive Neurosurgery; Issue 04, 1995

2.Chehrazi BB: A temporal transsylvian approach to anterior circulation aneurysms. Neurosurgery 30:957-961, 1992.

3.Day JD Surgical approaches to suprasellar and parasellar tumors. Neurosurgery Clinics of North America 14 109-122, 2003

4.De Oliveira E, Siqueira M, Tedeschi H, Peace DA. Technical aspects of the fronto-temporo-sphenoidal approach craniotomy. In: Matsushima T (Ed). Surgical anatomy for microneurosurgery VI: cerebral aneurysm and skull base lesions. Fukuoka City: Sci Med Publications: 3-8, 1993

5.Fahlbusch R, Schott W. Pterional surgery of meningiomas of the tuberculum sellae and planum sphenoidale: Surgical results with special consideration of ophthalmological and endocrinological outcomes. J Neurosurg.96:235-43, 2002

6. Figueiredo EG, Oliveira AM, Plese JP, Teixeira MJ. Perspective of the frontolateral craniotomies. Arq Neuropsiquiatr 68:430-432, 2010

7.Figueiredo EG, Deshmukh P, Zabramski JM, Preul MC, Crawford NR, Spetzler RF. The pterionaltranssylvian approach: an analytical study. Neurosurgery 2006; 59:263-269.

8.Heuer GJ. The surgical approach and treatment of tumors and other lesions about the optic chiasm. Surg Gynecol Obstet 53: 489-518, 1931

9.Hoffmann HJ, Craniopharyngiomas: the continuing controversy on management. Concepts Pediatr Neurosurg 2: 14-28, 1982

10.Jallo G, Benjamin V. Tuberculum sellae meningioma: Microsurgical anatomy and surgical technique. Neurosurgery. 51:1432-40, 2002

11. Kim E, Delashaw JB Jr. Osteoplastic pterional craniotomy revisited. Neurosurgery. 68:S125-S129, 2011

12.Knosp E. Practical Handbook of Neurosurgery from Leading Neurosurgeons. In: Sindou M, editor. Springer Verlag: New York; pp. 79-94, 2009

13.Liu JK, Weiss MH, Couldwell WT: Surgical approaches to pituitary tumors. Neurosurg Clin N Am 14:93-107, 2003

14.Nakamura M, Samii M. Berlin, Heidelberg: Springer Verlag; 2008. In: Ramina R, Aguiar PH, Tatagiba M, editors. Samii's Essentials in Neurosurgery. Springer Verlag: Berlin Heidelberg; pp. 98-105, 2008.

15.Nakamura M, Roser F, Struck M, Vorkapic P, Samii M. Tuberculum sellae meningiomas: Clinical outcome considering different surgical approaches. Neurosurgery.59:1019-29, 2006

16.Oreste de Divitiis, Enrico de Divitiis. Anterior Cranial Fossa Meningiomas: A New Surgical Perspective. World Neurosurgery 77:5-6, 623-624, 2012

17.Samandouras G, Kerr RS & Milford CA Minimally invasive biopsy of parasellar lesions: safety and clinical applications of the endoscopic, transnasal approach. British Journal of Neurosurgery 19 338-344, 2005

18.Samii M, Gerganov VM. Surgery of extra-axial tumors of the cerebral base. Neurosurgery. (Suppl 3):1153-61, 2008

19.Shulev, Yuri; Akobyan, Ovanes Pterional Approach to Management of Anterior Skull Base MeningiomasSkull Base; Issue 03, 2009

20.Stanila A, Florian IS et al, Ghid de Neurooftalmologie, Edit. Universitatii L.Blaga Sibiu, 2007; 54-78

21.Yaşargil MG, Curcic M, Kis M, Siegenthaler G, Teddy PJ, Roth P: Total removal of craniopharyngiomas. Approaches and long-term results in 144 patients. J Neurosurg 73:3-11, 1990

22..Yasargil MG, Krisht AF, Türe U, Al-Mefty O, Yasargil DCH. Microsurgery of insular gliomas: Part I. Surgical anatomy of the Sylvian cistern. Contemporary Neurosurgery 2002; 24:1-8.

23.Wen HT, Oliveira E, Tedeschi H, Andrade FC, Rhoton AL. The pterional approach: Surgical anatomy, operative technique, and rationale. Operat TechNeurosurgery 2001; 4:60-72.

Romanian Neurosurgery

The Journal of Romanian Society of Neurosurgery

Journal Information

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 215 133 15
PDF Downloads 62 51 8