Combined Endoscopic and Open Cranial Approach for Treatment of Skull Base Lesions: A Case Series and Lessons Learned

Abstract

Introduction

Surgical treatment of skull base pathologies is frequently discussed in the context of endoscopic endonasal or transcranial approaches. Combined endoscopic and open approaches have been utilized in a staged or sequential fashion, with the goal of reducing the risk of postoperative cerebrospinal fluid leak, morbidity, wound infection/complication, and failure to achieve adequate reconstruction. However, few studies have described the concurrent use of endoscopic endonasal and transcranial approaches to safely address complex skull base pathologies.

Methods

We treated 13 patients with primary skull base tumors (sinonasal undifferentiated carcinoma/esthesioneuroblastoma), recurrent tumors, infection, and skull base defect/encephalocele. Out of the thirteen patients, eight had undergone prior endoscopic and/or open transcranial approaches for resection of their pathologies. Additionally, 3/13 patients underwent radiation or chemotherapy radiation prior to the combined approach.

Results

The desired clinical outcome (i.e., gross total tumor resection, resolution of infection, and skull base resection/repair) was achieved in 12/13 cases. One case had subtotal resection (Simpson grade III) of an olfactory groove meningioma. Postoperatively, there was one 30-day mortality due to pulmonary infarction, one case with hydrocephalus requiring ventriculoperitoneal shunt placement, and one flap infection due to postoperative cocaine use resulting in revisions and hospice. Importantly, no patients experienced postoperative CSF leaks, including those who underwent postoperative chemotherapy/radiation.

Conclusion

This case series suggests that a concurrent combined endoscopic transcranial approach, in carefully selected patients, can treat a wide range of complex and recurrent skull base pathologies resistant to previous treatment, with a reasonable rate of postoperative wound/leak complications.

Keywords

skull base - endoscopic - endonasal

Publication History

Received: 12 August 2024

Accepted: 02 February 2025

Accepted Manuscript online:
04 February 2025

Article published online:
20 February 2025

• References

• 1 Kahilogullari G, Baykara Y, Eroglu U. et al. Comparison of three surgical approaches for frontobasal meningiomas: purely endoscopic endonasal, purely microscopic bifrontal transcranial, and combined endoscopic and microscopic supraorbital transciliary approaches. J Craniofac Surg 2021; 32 (03) 844-850
• 2 Kuga D, Toda M, Ozawa H, Ogawa K, Yoshida K. Endoscopic endonasal approach combined with a simultaneous transcranial approach for giant pituitary tumors. World Neurosurg 2019; 121: 173-179
• 3 Inoue A, Suehiro S, Ohnishi T. et al. Simultaneous combined endoscopic endonasal and transcranial surgery for giant pituitary adenomas: tips and traps in operative indication and procedure. Clin Neurol Neurosurg 2022; 218: 107281
• 4 Kondo T, Kishida Y, Watanabe T, Nagatani T, Seki Y. Combined transcranial-endonasal reconstructive surgery for cerebrospinal fluid leakage resulting from traumatic anterior skull base fractures involving the parasellar region. Neurol Med Chir (Tokyo) 2021; 61 (09) 557-562
• 5 Barzo P, Zador Z, Bodosi M. et al. Combined minimally invasive supraciliary and transfacial approach for large tumors with skull base and sinonasal involvement. World Neurosurg 2018; 109: 1-9
• 6 Ferreira FL, Bota DP, Bross A, Mélot C, Vincent JL. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 2001; 286 (14) 1754-1758
• 7 Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13 (10) 818-829
• 8 D'Ambrosio AL, Syed ON, Grobelny BT, Freda PU, Wardlaw S, Bruce JN. Simultaneous above and below approach to giant pituitary adenomas: surgical strategies and long-term follow-up. Pituitary 2009; 12 (03) 217-225
• 9 Han S, Gao W, Jing Z, Wang Y, Wu A. How to deal with giant pituitary adenomas: transsphenoidal or transcranial, simultaneous or two-staged?. J Neurooncol 2017; 132 (02) 313-321
• 10 Leung GK, Law HY, Hung KN, Fan YW, Lui WM. Combined simultaneous transcranial and transsphenoidal resection of large-to-giant pituitary adenomas. Acta Neurochir (Wien) 2011; 153 (07) 1401-1408 , discussion 1408
• 11 Joshi KC, Kolb B, Khalili BF, Munich SA, Byrne RW. Surgical strategies in the treatment of giant pituitary adenomas. Oper Neurosurg (Hagerstown) 2024; 26 (01) 4-15
• 12 Matsuda M, Akutsu H, Tanaka S, Ishikawa E. Significance of the simultaneous combined transcranial and endoscopic endonasal approach for prevention of postoperative CSF leak after surgery for lateral skull base meningioma. J Clin Neurosci 2020; 81: 21-26
• 13 Restelli F, Tabano A, Pozzi F, Castelnuovo P, Locatelli D. Combined multiportal endoscopic endonasal and transcranial approach for recurrent tuberculum sellae meningioma: operative video. World Neurosurg 2019; 127: 221
• 14 Attia M, Patel KS, Kandasamy J. et al. Combined cranionasal surgery for spheno-orbital meningiomas invading the paranasal sinuses, pterygopalatine, and infratemporal fossa. World Neurosurg 2013; 80 (06) e367-e373
• 15 Fischer-Szatmári T, Fülöp B, Szakács L, Gyura E, Bella Z, Barzó P. Combined simultaneous multiportal approach via minimally invasive transciliary and endoscopic endonasal approaches for tumors invading both the skull base and the sinonasal area. World Neurosurg 2021; 148: 70-79