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Clinical Neurology and Neurosurgery 129 (2015) 27–33

Contents lists available at ScienceDirect

Clinical Neurology and Neurosurgery

jo ur nal home p age: www.elsev ier .com/ locate /c l ineuro

ndoscope-assisted keyhole surgery via an eyebrow incision foremoval of large meningiomas of the anterior and middle cranial fossa

lhadi Igressaa, Ioannis Pechlivanisa, Friedrich Webera, Mehran Mahvasha, Ali Ayyadb,ahjouba Boutarbouchc, Patra Charalampakia,∗

Department of Neurosurgery, Hospital Merheim, University of Witten-Herdecke, Cologne, GermanyDepartment of Neurosurgery, University Medical Center Mainz, Mainz, GermanyDepartment of Neurosurgery, Mohamed Vth University, School of Medicine, Hôpital des Spécialités, ONO CHU Ibn Sina, Rabat, Morocco

r t i c l e i n f o

rticle history:eceived 5 September 2014eceived in revised form5 November 2014ccepted 29 November 2014vailable online 6 December 2014

eywords:eyhole neurosurgerykull base surgeryeningioma

ndoscope-assisted neurosurgeryupraorbital approach

a b s t r a c t

Background: Conventional open surgery of large meningiomas has proven to be challenging even in expe-rienced hands. Intense retraction and dissection around neurovascular structures increase morbidity andmortality. In the present study, we retrospectively analyzed the surgical technique, and outcome in 40patients with large anterior cranial fossa meningiomas extending to the middle fossa. All patients wereapproached via a supraorbital mini craniotomy.Methods: It is a retrospective study of 40 patients (12 males, 28 females) who underwent surgery forlarge anterior cranial fossa meningiomas (diameter >5 cm) extending to the middle fossa in four differentneurosurgical centers within 6 years. Depending on the localization of the tumor, the skin incision wasbetween 2.5 and 3 cm long and was made without shaving the patient’s eyebrow hair. Subsequently,a keyhole craniotomy was performed of approximately 0.8 × 1.2–1.4 cm in diameter. Preoperative andpostoperative clinical and radiological data were analyzed and discussed.Results: Headache and psycho-organic syndrome were the most common presenting symptom in allpatients. Presenting symptoms were associated with psychological changes in 23 cases, visual impair-ment in 19 patients, and anosmia in 17 patients. In overall, 36 of 40 patients (90%) showed a good outcomeand returned at long-term follow-up to their previous occupations. The elderly patients returned to theirdaily routine.

Conclusion: With the appropriate keyhole approach as a refinement of the classic keyhole craniotomy toa smaller key“burr”hole, and with use of modern and new designed equipment, it is possible to performcomplete resection of large anterior and middle fossa meningiomas with the same safety, efficiency andwith less complication rates as described in the literature for large meningiomas even performed withclassic keyhole craniotomies.

. Introduction

Conventional open surgery of large meningiomas has proveno be challenging even in experienced hands. Intense retractionnd dissection around neurovascular structures increase morbiditynd mortality [1,2]. However, minimally invasive surgical meth-

ds like the supraorbital craniotomy via an eyebrow skin incisionnd a subfrontal approach with minimal brain retraction showedany improvements according to surgical results and outcomes

∗ Corresponding author at: Department of Neurosurgery, Hospital Merheim, Uni-ersity Witten-Herdecke, Ostmerheimerstr. 200, 51109 Cologne, Germany.el.: +49 221 8907 13772; fax: +49 221 8907 3779.

E-mail address: charalampaki@yahoo.de (P. Charalampaki).

ttp://dx.doi.org/10.1016/j.clineuro.2014.11.024303-8467/© 2014 Elsevier B.V. All rights reserved.

© 2014 Elsevier B.V. All rights reserved.

especially in the frontal and middle fossa [1]. Furthermore, thesupraorbital surgical technique combined with the use of neu-roendoscopy has been shown to be a very effective method in theresection of meningiomas in the anterior skull base [1,3].

In the last two decades, two major routes have been estab-lished to approach meningiomas located in the olfactory groove,tuberculum sellae, planum sphenoidale or the medial part of sphe-noid wing. These two routes are the endonasal transsphenoidalapproach and the supraorbital craniotomy. Both approaches bene-fits from endoscopic techniques.

The transsphenoidal approach has been shown to be effective

and safe for suprasellar tumors that are predominantly locatedin the midline medial to the carotid arteries [4–15]. With thisapproach, there is no brain retraction, the optic apparatus manip-ulation is significantly low, and early identification of the pituitary

28 A. Igressa et al. / Clinical Neurology and Neurosurgery 129 (2015) 27–33

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Fig. 1. (A) Size of a small keyhole craniotomy and the s

land and infundibulum is common [6]. The supraorbital “eyebrow”raniotomy is also performed with minimal brain retraction andllows excellent access to the frontal base, the medial part of theiddle fossa and under endoscopic visualization a panoramic view

ver the whole supra- and parasellar area [3,16,17].In the present study, we analyzed surgical technique, and out-

ome in 40 patients with large meningiomas located in the frontalossa and partly extended into the middle fossa. All patients werereated via a keyhole craniotomy as large as necessary to host thenstruments and as small as possible to achieve the best surgicalesult. Furthermore, we compared surgical strategy with conven-ional fronto-temporal and pterional approaches presented in theiterature for removing large fronto-temporo-basal meningiomas.

. Patients and methods

.1. Patient population

Within 6 years (2008–2013), 40 patients (12 males, 28 females)nderwent surgery in the frontal and temporal skull base for largeeningiomas in four different neurosurgical centers. We define theeningiomas as large if the diameter was bigger then 5 cm. Menin-

iomas were located bilaterally in the olfactory groove (n = 17),uberculum sellae (n = 7), medial sphenoid wing (n = 12, right sided

= 7, left sided n = 5), planum sphenoidale (n = 3), and anterior sidef the falx cerebri (n = 1) (Table 1). The mean patient age was 59ears (range, 38–80 years).

All patients underwent postoperative MRI during the follow-uperiod at 1 week, 3 months, 12 months, and every year thereafter.thical approval for performing the retrospective study was noteeded.

able 1ummary of characteristics in 40 patients with giant intracranial meningiomas.

Characteristics No. of patients (%)

Preoperative symptomsPsychological deterioration 23 (57.5%)Visual disorder 19 (47.5%)Anosmia 17 (42.5%)

Resection Simpson gradeSimpson I 32 (80%)Simpson II 8 (20%)

Histology subtypeMeningothelial 19 (47.5%)Fibroplastic 10 (25%)Transitional 5 (12.5%)Psammomatous 3 (7.5%)Atypic WHO II 3 (7.5%)

the eyebrow incision and (B) bone flap measurement.

2.2. Surgical performance

Depending on the localization of the tumor, the skin incisionwas between 2.5 and 3 cm long and was made without shaving thepatient’s eyebrow hair. Subsequently, a key“burr”hole craniotomywas performed of approximately 0.8 × 1.2–1.4 cm in diameter. Pri-mary goal was radical tumor removal, Simpson I◦. Surgical time was3–6 h, depending on the consistence of the tumor, the infiltrationof the olfactory, optic and oculomotor nerve. Skin incision followedthe shape of the eyebrow without shaving it, started lateral to thesupraorbital foramen and remained strictly into the eyebrow. After-wards, the subcutaneous tissue was carefully dissected frontally.The frontal muscle was cut and the temporal muscle retractedlaterally, the typical key“burr”hole was placed fronto-basal andposterior to the temporal line (Fig. 1A). The bone flap had an ellip-soid shape with extensions maximal to 0.8 × 1.2–1.4 cm (Fig. 1B).

After bone removal the most important step of the craniotomywas drilling the inner edges of the skull to widen the surgical cor-ridor. Small osseous extensions of the superficial orbital roof weredrilled extradural to achieve better visualization after dura opening.The view into the entire skull base ipsi- and contralateral improvedwhile debulking the tumor.

Intradural tumor dissection was performed intermittently usingmicroscope (Fig. 2A), and endoscope on an endoscope-assisted,endoscope-controlled technique basis.

The 3D-endoscope was placed on a holding arm for fixationabove the surgical field. After the craniotomy was done, the 3D-endoscope was placed above the surgical field like a microscope,and the optical information was given to the surgeon via the inte-grated monitor placed in front of the surgeon’s eyes. Next stepwas to creating the surgical corridor with the help of the operatingmicroscope, and in interchange to the 3D-endoscope the tumor wasdebulked. At the end of the surgery the 3D-endoscope helped thesurgeon to remove the lesion remaining above the neurovascularstructures with spending light and sight in front of the target point.We transformed the monitor of the 3D-endoscope unit to a kind“occular” of the surgical microscope. The light and sight in the sur-gical region of interest came from the positioning of the telescopeabove the surgical field.

CUSA was not used because of in situ ergonomic problems. Thecraniotomies were as minimal as that ultrasonic dissector could notbe introduced to reach these deep-seated skull base meningiomas.For tumor removal, the below described tube shaft microinstru-ments, in combination with bipolar, scissors, different dissectors

and small suction devices were used.

Tumor removal strategy followed an interaction between tumormatrix coagulation, cutting, debulking, and at the end careful dis-section between skull base, neurovascular structures and remained

A. Igressa et al. / Clinical Neurology and Neurosurgery 129 (2015) 27–33 29

Fig. 2. (A) Classical microscopic view in the suprasellar cistern; (b) 3D microendoscopic view in the suprasellar cistern; (C) 3D microendoscopic view between differ-ent anatomical windows; (D) 3D microendoscopic view on the contralateral internal carotid artery bifurcation, anterior cerebral artery, middle cerebral artery, and thecontralateral mesial part of the temporal lobe.

Fig. 3. Preoperative and postoperative MRI scans of an olfactory groove meningioma.

30 A. Igressa et al. / Clinical Neurology and Neurosurgery 129 (2015) 27–33

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Fig. 4. (A–C) Preoperative and (D–F) postoper

umor. This last step was always performed under endoscopic viewFig. 2B–D).

. Results

Headache and psycho-organic syndrome were the most com-on presenting symptoms in all patients. Psychological changes

n 23 cases (57.5%), visual impairment in 19 patients (47.5%), andnosmia in 17 (42.5%) patients.

Psychological changes improved in the first 3 months postop-rative in 13 of 23 patients. One year follow-up 18 of 23 patientsere able to do their daily routine work on a satisfied level.

In 10 of 17 patients presenting with preoperative anosmia,lfactory function improved postoperatively. Ipsi- and contralat-ral anatomical conservation of the olfactory nerve was possible in2 patients and contralateral in all 17 patients.

Fig. 5. (A) Cosmetic results of a right-sided eyebrow i

RI scans of a tuberculum sellae meningioma.

19 patients presented with preoperative bilateral visual acuitydeficits. In 10 patients the deficit was significantly worse in one eye,whereas in 2 patients it impaired equally in both eyes. Visual deficitexamination revealed bitemporal hemianopia in three patientsand temporal unilateral hemianopia in 8 cases. The visual deficitimproved in 12 of 19 patients (63.2%) and remained stable in 7(36.8%). No worsening in the visual field was detected postop-eratively. Postoperative improvement was achieved in both visualacuity and visual field deficits.

The mean tumor volume was 53.51 ± 0.62 mm3. Hyperostosiswas evident in six cases, and calcifications in four cases. The meanmaximum tumor diameter was 6.85 cm (Fig. 3). The optic tract

was compressed and stretched in 12 patients. Paranasal sinus inva-sion was found in none of the patients. In four patients completeremoval of the meningioma required decortication of the opticcanal.

ncision 1 week and (B) 3 months postoperative.

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All meningiomas arising from the sphenoid wing (12 patients)ere extended into the middle fossa with impression of the

pto-carotic complex. Nine of these 12 patients presented with pre-perative visual impairment. At follow up examination 3 monthsfter surgery all patients showed an improvement on vision andisual field.

Tumors located on the planum sphenoidale and tuberculum sel-ae (Fig. 4) partially extended into the sella region and compressedhe optic chiasm and the pituitary stalk. The main symptomsf patients harboring these tumors were optical field deterio-ation with bitemporal hemianopia and hormonal disturbancesith partial pituitary insufficiency. In this case no compression of

ntracranial vessels or cranial nerves occurred.One tumor originating from the falx cerebri caused as solely

ymptom mental deterioration.In 32 of 40 patients (80%) tumor resection was possible as grade

resection (Simpson grade I). In 8 patients (20%) coagulation ofumor dural attachment (Simpson grade II) were achieved.

MRI follow-up after 1 week, 3, 12, 24, 48, and 56 months post-perative presented no evidence of tumor recurrence. Tumors

able 2eries of giant meningiomas reported in the literature.

Authors and year No. ofpatients

Tumor location Mean tumordiameter (cm)

Attia et al. (2012) 22 Anterior clinoidal 5.9

Behari et al. (2008) 20 Medial sphenoid wing 6.1

Gazzeri et al. (2008) 36 Olfactory groove 6.4

Jiang et al. (2006) 56 Cerebellopontine angle >4.5

Quinones-Hinojosaet al. (2009)

67 Convexity (n = 17),parasagittal (n = 11),falx (n = 6), sphenoidwing (n = 11),suprasellar (n = 7),olfactory groove (n = 6),clivus/foramenmagnum (n = 5),cerebellopontine angle(n = 2), cerebellum(n = 2)

6.3

Romani et al. (2009) 25 Olfactory groove >6

Solheim et al. (2009) 15 Convexity (n = 2),olfactory groove (n = 3),midline cerebral (n = 1),sphenoid ridge (n = 5),anterior clinoidal(n = 1), falx (n = 3)

>5

Tomasello et al. (2011) 18 Sphenocavernous 6.8

Tzortzidis et al. (2005) 20 Olfactory groove(n = 16), tuberculumsellae (n = 6)

>4.5

Present study 40 Olfactory groove(n = 17), tuberculumsellae (n = 7), medialsphenoid wing (n = 12),planum sphenoidale(n = 3), anterior sidefalx cerebri (n = 1)

5.3

Neurosurgery 129 (2015) 27–33 31

were classified as WHO grade I in 37 and WHO grade II in 3cases.

We performed 42 surgical procedures in 40 patients. One patientdeveloped a CSF leak with a pneumocephalus and had to be revisedfor closing the basal bony defect. Another patient developed anacute subdural hematoma and has to be revised for hematomaevacuation 24 h postoperatively. No further morbidity or mortalityoccurred. The skin scar was within one week cosmetically very wellhealed (Fig. 5A), and invisible at 3 months postoperative (Fig. 5B).

Overall, 36 of 40 patients (90%) showed a good outcome toour criteria and returned long-term to their previous occupationsrespectively the elderly patients to their daily routine withoutneeded of additional external support. Four patients did not getback in their daily routine because of severe psychological deficits.

4. Discussion

One of the first neurosurgeons who used the term “key-hole surgery” for limited exposures was Donald Wilson, 1971,

Approach Gross-totalresection

Follow-up(years)

Tumorrecurrence

Outcomegood

Extradural (Dolenctechnique),

7 (30.4%) 4.7 3 (13.6%)

Frontotemporal(n = 13), frontotempo-ral/orbitozygomatic(n = 7)

9 (45%) 1.5 0 13 (65%)

Bifrontal (n = 35),frontotemporal (n = 1)

31 (86%) 9.3 2 (5.5%)

Suboccipital-retrosigmoidal (n = 38),temporal-occipital,presigmoidal (n = 6),temporal-occipital,inferotemporaltentorium cerebelli(n = 8),temporal-occipital,supratento-rial/infratentorial allied(n = 4)

44 (79%) 3.5

Bifrontal 39 (58%)

Lateral supraorbital 3.8 11 (44%)Frontotemporal 12 (80%) 15 (100%)

Pterional 17 (94%) 7.8 3 (16.7%) 17 (94%)Subfrontal (n = 16),fronto-orbitozygomatic(n = 4)

20 (100%) 5.3 1 (5%) 20 (100%)

Supraorbital 40 (100%) 3 0 36 (90%)

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escribing that the extension of a craniotomy should be widenough to be able to treat surgically the lesion and small enougho perform the minimum of damage of the healthy brain tissueurrounding the pathology [18]. Perneczky, 1999, described andodified the term “keyhole” as a concept approaching pathological

esions in definite intracranial areas [8,19].Because of the minimal size of the supraorbital craniotomy we

sed over the past years for surgical removal of the describedarge skull base tumors, we redefined the term from “keyhole” toey“burr”hole trephination. In general, the regular mean measure-ent of a burr hole is approximately 1 cm in diameter like the mean

ize of our performed craniotomies in this study.In our series we presented 40 patients with large meningiomas,

ho underwent surgical removal, under endoscopy-assistancesing a key“burr”hole craniotomy. Due to the neurovascular struc-ures of the skull base, especially located in the suprasellar area,xcision of large meningiomas of the anterior and middle cranialossa can be very challenging. Moreover, the supraorbital approachas been reported as a successful approach to resect anterior cranial

ossa tumors [3,16,20,21] and clipping aneurysms of the ante-ior circulation [3,17,22]. This approach is ideally suited for thereatment of tumors of the anterior and middle skull base [23].urthermore, it is especially recommended for meningiomas largerhan 30–35 mm, those extending lateral to the supraclinoid carotidrteries, or those with vascular or lateral optic canal encasement24]. The approach is indicated for clinoidal meningiomas, olfac-ory groove meningiomas, meningiomas of the cavernous sinus anduprasellar meningiomas [25]. The advantages of this approach areaximal exposure with minimal skin incision, enhancing visual-

zation of the pathology and of the surrounding structures [25,26].hus the supraorbital nerve and artery, the frontal branch ofhe facial nerve, and the superficial temporal artery are com-

only spared. Reduced manipulation of the temporal musclereserves it functionally and anatomically, avoiding unpleasantost-operative hypotrophy, muscle fibers injury, or muscle tensionfter readaptation [27]. With proper technique, excellent cosmeticesults are achieved [18]. Disadvantages are the risk of scalp anes-hesia and CSF fistula through an occult frontal sinus opening25,26].

In our series we showed that this technique could be useduccessfully also for complete resection of large meningiomasxtending from the frontal to the middle cranial fossa. The extent ofesection correlates significantly with the time to recurrence [28].lmost the half of the incompletely resected tumors (47%) relapsedithin the first 5 years after the first resection and thereby signifi-

antly more frequently than the macroscopically complete resectedeningiomas (12%) [29].In the literature there are few series about surgery of large

eningiomas [2,30–37]. In the present study in all cases a com-lete removal of the tumor (Simpson grade I or II) was achieved.his was higher than in any other study published till now. Overall,6 of 40 patients (90%) had a good outcome. Only in two studies

better outcome was reported, but the patient number was lowerTable 2).

Only one patient (2.5%) developed a CSF leakage with a pneu-ocephalus. In the series of Romani et al. [34], with a lateral

upraorbital approach, six patients (9%) had CSF leakage. Theuthors explained the leakage by infiltration of the tumor into thethmoid bone and drilling to prevent recurrences.

The use of a small eyebrow skin incision and very smalley placed craniotomy may cause at a first glance the impres-ion of a limited working window. In our series we used a

ean of 1–1.1 cm craniotomy. In order to overcome the limited

ccess, special designed microsurgical instruments as well asndoscope-assisted resection were mandatory. The use of neuroen-oscopes provided a clear visualization to deep structures in hidden

[

Neurosurgery 129 (2015) 27–33

corners ipsi- and contralateral view for clarify the pathoanatomybefore, after, and during tumor removal. Hence, it was a keyfactor achieving a safe and precise guided tumor resection andsecuring coagulation. We performed near almost all surgeriesusing the 3D microendoscope, without having ergonomic prob-lems in acting and manipulating on the tissue during surgicalremoval.

In contrast to the classical larger scalp flap, the supraorbitalapproach was associated with more acceptable postoperativewound healing results [38]. Regarding the risk of frontal nervepalsy, we used a small skin incision, respecting the anatomicalpathway of the supraorbital nerve route.

The supraorbital approach for tumor removal has a relativelylow morbidity and no mortality. In our study no patient devel-oped facial nerve palsy postoperatively. Furthermore, except twopostoperative complications of a pneumocephalus and an acutesubdural hematoma no other complications occurred.

Our experience with this approach confirmed the findings ofWilson et al. [39] that the simplicity and versatility of the supraor-bital approach make it one of the most efficient and useful skullbase techniques even for big skull base lesions.

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