Todeschini Alexandre B, Shahein Mostafa, Montaser Alaa S, Hardesty Douglas, Otto Bradley A, Carrau Ricardo L, Prevedello Daniel M
Department of Neurological Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, Ohio.
Department of Neurological Surgery, Ain Shams University, Cairo, Egypt.
Oper Neurosurg. 2019 Jan 1;16(1):115-116. doi: 10.1093/ons/opy092.
A 42-yr-old female presented with an olfactory groove meningioma causing progressive vision loss and anosmia. Given the size of the tumor, we opted for a 2-stage surgery: endoscopic endonasal approach (EEA) followed by a craniotomy. Stage I surgery was a transcribriform transplanum EEA using a binostril 4-hand/2 surgeons (ENT and neuro) technique, with the patient positioned supine with the head slightly turned to the right side and tilted to the left, fixed in a 3-pin head clamp, under imaging guidance, in which we drilled out all the affected skull base bone, devascularized and debulked the tumor. Stage II surgery was done through a right frontotemporal craniotomy 2 mo later. The surgery and postoperative period was uneventful with no complications and no need for further reconstruction of the skull base. The patient's vision was normalized. Postoperative magnetic resonance imaging (MRI) confirmed a Simpson Grade 1 resection. The rationale behind this staged approach is that we have found when using a transcranial 1-stage approach the brain edema and necessary retraction required for resection leads to brain injury, oftentimes readily identified in the diffusion-weighted imaging MRI which are associated with different degrees of cognitive impairment. The skull base bone involved is usually not removed via transcranial approaches. Despite requiring a second surgery, this staged approach allows a true total resection (including the affected bone) and in the transcranial stage the brain is more relaxed, with less edema, reducing the need for retraction, which may lead to a better outcome. The patient has given assent and written consent for videos, images, or clinical or genetic information to be published.
一名42岁女性因嗅沟脑膜瘤导致视力进行性丧失和嗅觉缺失前来就诊。鉴于肿瘤大小，我们选择了两阶段手术：先采用鼻内镜经鼻入路（EEA），然后进行开颅手术。第一阶段手术是经筛板经蝶骨平台的EEA，采用双侧鼻孔四手/两名外科医生（耳鼻喉科医生和神经外科医生）技术，患者仰卧位，头部稍向右侧转动并向左倾斜，用三钉头夹固定，在影像引导下，我们钻除所有受累的颅底骨质，使肿瘤血管离断并部分切除。第二阶段手术在2个月后通过右额颞开颅进行。手术及术后过程顺利，无并发症，无需进一步进行颅底重建。患者视力恢复正常。术后磁共振成像（MRI）证实为辛普森1级切除。这种分期手术方法的依据是，我们发现采用经颅一期手术时，切除所需的脑水肿和必要的牵拉会导致脑损伤，在扩散加权成像MRI中通常很容易识别，这与不同程度的认知障碍有关。经颅手术通常无法切除受累的颅底骨质。尽管需要二次手术，但这种分期手术方法能够实现真正的全切（包括受累骨质），并且在经颅手术阶段，大脑更为松弛，水肿较少，减少了牵拉的必要性，这可能会带来更好的结果。患者已同意并书面许可发布视频、图像或临床或基因信息。
