The using of endoscopic technology in transcranial neurosurgery of tumors chiasmosellar region and arterial anterior ring aneurysm
Objective – to study the experience and technical possibilities of the optimal using of the endoscopic assistance during different stages of intracranial surgical procedures in patients with chiasmal–sellar tumors (CST) and arterial aneurysms (AA) of the anterior circulation (AC).
Materials and methods. The results of initial series of 59 patients with CST and 14 patients with AA of the AC who were operated at Romodanov Neurosurgery Institute NAMS of Ukraine between 2012 to August 2017, with the using of endoscopic assistance at the different stages of procedure were analyzed. There were used following methods: clinical and neurological exams, laboratory measurements, instrumental evaluation, neuroimaging (brain Computer Tomography (CT), CT Angiography, brain Magnetic Resonance Imaging (MRA), Magnetic Resonance Angiography (MRA), Digital Subtraction Angiography (DSA) of cerebral vessels), functional (Doppler Ultrasound (DU) of the head and neck vessels), morphological evaluation, electroencephalography, statistical analysis.
Results. The choice of surgical tactics and approach for CST was performed considering the localization and expansion of CST on the seller region (ante, retro, para, endosellar) and three-dimensional virtual and material modeling. According to the histological type, distribution of CST was follow: tuberculum and diaphragm sellar meningioma – 22 (37.2%) cases, craniopharyngioma – 15 (25.5%), pituitary adenomas – 14 (23.8%), epidermoid and dermoid cysts – 5 (8.5%), optic nerve gliomas – 3 (5.1%). Craniotomy approaches was follow: supraorbital – in 25 (42.4%) patients, pterional – in 18 (30.5%), modified orbitozygomatic- in 16 (27.1%). In 48 (81.3%) cases, initial removal was done, and in 11 (18.7 %) – repeated surgical interventions (regrowth and residual growth of the pituitary adenoma – 7 (63.6%) cases, craniopharyngioma – 4 (36.4%). Microscopic tumor removal were considered as radical in 46 among 56 patients (82.1%). Postoperative mortality was 2.49% (1 patient). The new onset of diabetes insipidus occurred in 3 (5.1%) observations, transient functional disorders, including cosmetic – in 38 (64.4%). Thirty-two (54.3%) patients showed an improvement of visual function (expansion of vision fields, regression of scotomas and / or increased of visual acuity according to Kadasheva scale assessment).
Patients with AA of the AC underwent microsurgical procedure under endoscopic assistance and measuring the depth of the wound and the angles of the surgical field during pterional approach – in 9 (64.3%), orbitozygomatic – in 1 (7.1%), pterional with anterior clinoidectomy – in 2 (14.3%), infratemporal – in 2 (14.3%) cases.
The evaluation of results included an assessment of AA clipping: Simple clip – 6 (42.9%), Multiple clips – 8 (57.1%). Following intraoperative complication was seen – AA rupture in 1 (7.1%) case, and secondary postoperative ischemic complication in 1 (7.1%) case. The grade of AA exclusion from the blood flow after clipping was done according to Raymond scale: class I – 13 (92.9%) cases, class II – 1 (7.1%). The quality of life of the surgical treated patients was evaluated using Extended Glasgow Outcome Scale. Full and good recovery was observed in 6 (42.9%) patients, mild dependence in 4 (28.6%), moderate dependence in 4 (28.6%).
Conclusions. Endoscopic assistant should be used during tumor inspection, its dissection and for control of radical removal considering the size of the bone window, parameters of surgical approach and quality of microscopic visualization. Extreme importance has the utilization of endoscopic assistance for controlling of tumor removal, since its remaining may be inaccessible for microscopic examination, which is situated in «blind» spots. Endoscopic assistance during different stages of clipping of AA of the AC is accessory technique that improves intraoperative visualization during separation of the affected aneurysmal arterial segment of the AC, determining the anatomical location of the perforating arteries, AA neck regions, assessment of the clip / clips position on the AA neck or AA body without additional traction on the wound margins, and for inaccessible regions for microscope examination.
Decq P. Endoscopy or microsurgery: is the never-ending debate concerning the choice of surgical strategy for colloid cysts of the third ventricle still a topical issue or has it been resolved? World Neurosurg. 2013 Nov;80(5):498-9. doi: 10.1016/j.wneu.2012.10.034. Epub 2012 Oct 24.
Berhouma M, Jacquesson T, Jouanneau E. The fully endoscopic supraorbital trans-eyebrow keyhole approach to the anterior and middle skull base. Acta Neurochir. 2011;153(10):1949-54. doi: 10.1007/s00701-011-1089-z. Epub 2011 Aug 5.
de Divitiis E, de Divitiis O, Elefante A. Supraorbital craniotomy: pro and cons of endoscopic assistance. World Neurosurg. 2014 Jul-Aug;82(1-2):e93-6. doi: 10.1016/j.wneu.2013.03.027. Epub 2013 Mar 21.
Lan Q, Chen AL, Zhang T et al. Zhonghua Yi Xue Za Zhi. 2016 Aug 9;96(30):2434-7. doi: 10.3760/cma.j.issn.0376-2491.2016.30.015. (in Chinese).
Hirurgiya anevrizm golovnogo mozga: Ruk-vo v 3 t. Pod red. V.V. Kryilova. M.: Izd-vo T.A. Alekseeva; 2011. 2012 p. (In Russian)
Dannenbaum MJ et al. Natural history of giant intracranial aneurysms. In: Cerebral revascularization. Techniques in extracranial-to-intracranial bypass surgery. I. Abdulrauf Saleem, editor. Elsevier Saunders; 2011: 225-30. ISBN: 9781437717853
Nieuwkamp D, Setz LE, Algra A et al. Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex and region: a meta-analysis. Lancet Neurol. 2009;8(7):635-42. doi: 10.1016/S1474-4422(09)70126-7. Epub 2009 Jun 6.
Lawton M. Seven aneurysms: tenets and techniques for clipping. New York: Thieme Medical Publishers; 2011. P. 224.
Buell T, Ding D. Optimizing the management of aneurysmal subarachnoid hemorrhage: Lessons learned and future directions J. Neuro. Rural. Pract. 2014;5(2):108-10. doi: 10.4103/0976-3147.131643.
Рeris-Celda M, Da Ros L, Monroy-Sosa A et al. Surgical anatomy of endoscope-assisted approaches to common aneurysm sites. Neurosurgery. 2014 Mar;10 Suppl 1:121-44; discussion 144. doi: 10.1227/NEU.0000000000000205. PMID: 24141479.
Wurm G, Lehner M, Tomancok B et al. Cerebrovascular biomodeling for aneurysm surgery: simulation-based training by means of rapid prototyping technologies. Surgical innovation. 2011 Sep;18(3):294-306. doi: 10.1177/1553350610395031.
Abla AA, Lawton MT. Three-dimensional hollow intracranial aneurysm models and their potential role for teaching, simulation, and training. World Neurosurgery. 2015 Jan;83(1):35-6. doi: 10.1016/j.wneu.2014.01.015. Epub 2014 Jan 29.
Kato Y, Sano Y, Behari S et al. Surgical clipping of basilar aneurysms: relationship between the different approaches and the surgical corridors. Minim Invasive Neurosurg. 2002;45:142-5. PMID: 12353160. DOI: 10.1055/s-2002-34351.
Raymond JG, Proust F, Molyneux AJ, Fox AJ. Unruptured intracranial aneurysms: a critical review of the International Study of Unruptured Intracranial Aneurysms (ISUIA) and of appropriate methods to address the clinical problem. Interventional Neuroradiology. 2008;14(1):85-96. doi:10.1177/159101990801400111.
Аdaptovana klinichna nastanova, zasnovana na dokazah «Gemoragichniy insult, anevrizmalniy subarahnoyidalniy krovoviliv». URL: http://mtd.dec.gov.ua/images/dodatki/2014_275_GI/2014_275_AKN_anevryzmkrov_GI.pdf (In Ukrainian)
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