Clinical significance of skull base fracture in patients after traumatic brain injury

About 4% of all head injuries include skull base fractures. Most of these fractures (90%) are secondary to closed head trauma; the remainder are due to penetrating trauma. We reviewed the records from January 2006 through December 2008 of all patients older than 18 years of age who arrived at Soroka Medical Center in Be’er-Sheva, Israel, with skull base fractures following a traumatic brain injury (TBI). We identified 107 patients with a mean age of 42 years at the time of TBI. Glasgow Coma score on arrival predicted the clinical outcome. We observed temporal fractures in 30% of these patients, occipital fractures in 20%, pyramidal fractures in 19%, anterior skull base fractures in 17%, and multiple fractures in 14%. Cerebrospinal fluid (CSF) leak was observed in 16 patients (15%). Of the patients experiencing CSF leaks, otorrhea occurred in 10 (62%) and rhinorrhea occurred in six (37%). Three patients required surgical intervention to repair the leak. Meningitis occurred in four patients with clinically evident CSF leak. Multiple skull base fractures are associated with poor neurological outcome. The low rate of meningitis in this patient sample implies that there is no indication to administer prophylactic antibiotics to patients with skull base fractures.     

经眶入路神经内镜手术治疗蝶眶脑膜瘤的疗效分析

目的 探讨经眶入路神经内镜手术治疗蝶眶脑膜瘤的疗效。方法 回顾性分析2015年12月至2021年2月经眶入路神经内镜手术治疗的18例蝶眶脑膜瘤的临床资料。结果 经眶入路手术9例,扩大经眶入路手术9例。肿瘤全切除3例,次全切除4例,部分切除11例。未全切除的15例中,13例肿瘤累及海绵窦,8例有眶内受累,8例有鞍旁、翼腭窝、颞下窝或颞肌受累。11例术后辅助伽玛刀治疗,1例术后辅助放疗。术后出现一过性眼球外活动受限3例,感觉减退2例,脑脊液漏1例。与正常侧相比,患侧眼眶软组织体积减少（91.18±8.19）%,术后眼眶软组织体积增加（113.73±12.92）%。术后眼球突出程度[（1.5±1.9）mm]较术前[（4.2±2.3）mm]明显降低（P<0.05）。10例压迫性视神经病变视力、视野明显改善。术后未出现视力恶化。18例术后平均随访（20.4±10.4）个月,2例肿瘤进展,2例肿瘤复发。结论 经眶入路神经内镜手术是治疗蝶眶脑膜瘤的一种有效方法,对肿瘤切除是有效的,而且不会引起严重的不良反应,对压迫性视神经病变也很一定的疗效。     

Reconstructive outcome of intraoperative cerebrospinal fluid leak after endoscopic endonasal surgery for tumors involving skull base

Endoscopic transnasal surgery for tumors located at the base of the skull has a high incidence of postoperative cerebrospinal fluid (CSF) leaks. Here, we assessed the repair outcomes for high-flow CSF leaks based upon the tumor location, and analyzed the reasons for repair failure after transnasal endoscopic surgery solely for tumors involving the base of the skull. From Feb. 2009 to Dec. 2014 we performed endoscopic endonasal surgery for a variety of skull base lesions in 788 patients at our institution. Among them, 95 patients with intradural skull base tumors underwent endoscopic transnasal surgery. We performed surgical repairs with a multilayered nonvascularized construct (38 patients) and a vascularized pedicled nasoseptal flap construct combined with a fascia graft (57 patients). Overall, 14 of 95 patients (14.7%) who underwent endoscopic transnasal surgery for skull base tumors developed postoperative CSF leaks. The major causes of repair failure included graft disruption by a lack of counter-pressure in the multilayered non-vascularized technique, and inadequate drilling of the sphenoid bone, displacement of the flap due to pressure from CSF or gravity, or disruption of flap integrity in the vascularized pedicled flap technique. Logistic regression analysis revealed that there was no significant association between repair failure and age, sex, type of reconstructive method used, and primary tumor type (p > 0.05). Reconstruction after endoscopic endonasal surgery remained challenging, especially for non-pituitary skull base tumors requiring intra-arachnoidal dissection. Recent advances in reconstructive techniques require the accumulation of experiences with sufficient dexterity to achieve an acceptable morbidity rate.     

Application of skull base techniques to pediatric neurosurgery

Techniques for skull base surgery have become well established over the last 10 years. Most of these techniques are used in adult patients for skull base tumors and neurovascular diseases. There are very few large series of pediatric patients in whom skull base approaches have been used, because of the rarity of these conditions. The authors would like to present a relatively large series of 26 pediatric patients who underwent skull base approaches for tumor resection. These tumors involved the anterior cranial base in 5 patients, the medial cranial skull base in 4 patients, and the posterior cranial base in 12 cases. Five patients had tumors that involved two or more fossae. The overall complication rate was 57%, which included temporary cranial nerve palsies, CSF leak and infection. Patients with permanent complications were 8 in number (37%). There was 1 postoperative death from pneumonia approximately 6 weeks after surgery. Complete tumor removal was achieved in 24 of the 26 patients. Skull base tumors in children are often extensive and present significant surgical challenges. Although complete tumor extirpation is the goal in most pediatric patients, this is often achieved only with some morbidity. This paper demonstrates the effectiveness of skull base approaches for these tumors and underscores the high stakes involved. Received: 1 October 1998     

颅底沟通性肿瘤的外科治疗

目的 探讨颅底沟通性肿瘤的临床特点、手术入路以及术后重建的方法。方法 将颅底划分为不同的区域，按照肿瘤主体累及的部位的不同选用不同的手术入路。采用显微手术，部分辅以内镜切除肿瘤，应用钛板修复颅底骨缺损，近手术区域筋膜、骨膜瓣翻转和背阔肌游离肌皮瓣移植血管吻合修复术后颅底和颅颌面的脑膜缺损和软组织缺损。结果 本组43例，肿瘤全切除32例，近全切除7例，部分切除4例，术后40例临床症状改善，并发症主要为颅神经损伤6例。术后门诊随访30例，随访时间5—20个月，平均9个月，复发3例，无脑脊液漏、颅内感染及其他严重并发症。结论 颅底沟通肿瘤的外科治疗较复杂，选用个性化的手术入路，精细的显微操作，配合使用内镜，加之可靠的颅底修复与重建，可以获得较好的临床疗效。     

Anatomic study of the anterior skull base via an endoscopic transnasal approach

Objectives

With rapid advances in endoscopic neurosurgery, it has become possible to treat some lesions located in the anterior skull base through a transnasal approach. This anatomic study was undertaken to describe the area of surgical exposure of the anterior skull base afforded by transnasal approaches with an endoscope, as well as to provide references for clinical practice.

Methods

Thirty bony skull base specimens (all Chinese) were used, and 10 injected adult cadaver heads (all Chinese) were dissected for a simulated endoscopic transnasal approach to the anterior skull base. The distance between the bilateral optic canals was measured in skull base specimens and the distance between the columella and anterior ethmoid artery or posterior ethmoid artery was measured on both sides in adult cadaver heads.

Results

The optic canals were 15.13 ± 1.69 mm apart. The distance between the columella and posterior ethmoid artery was 71.01 ± 3.99 mm on the left side and 72.27 ± 3.97 mm on the right side. The distance between the columella and anterior ethmoid artery was 64.811 ± 3.74 mm on the left side and 64.18 ± 3.74 mm on the right side. The endoscopic transnasal approach to the anterior skull base exposed the optic protuberance, sellar floor, crista galli, anterior ethmoid artery, and posterior ethmoid artery. In addition, bilateral olfactory bulbs, olfactory tracts, and optic nerves beneath the dura mater were also revealed.

Conclusions

The anatomic data as well as established anatomic landmarks associated with endoscopic surgery would benefit clinical practice.     

颅底脑膜瘤的治疗进展

瘤基底与前、中、后颅凹底附着的脑膜瘤统称为颅底脑膜瘤,约占脑膜瘤的35%～50%.颅底解剖结构复杂,颅底脑膜瘤常包裹脑神经、基底动脉、颈动脉及其分支,甚至侵袭脑干.     

Hemostasis in endoscopic endonasal skull base surgery using the Aquamantys bipolar sealer: Technical note

BackgroundA major challenge during endoscopic transsphenoidal surgery is adequate intraoperative hemostasis. The Aquamantys® is a relatively new bipolar sealing device which uses radiofrequency energy and saline. This promotes hemostasis while decreasing charring and thermal spread. In this paper, we describe our experience with the Aquamantys® Mini EVS 3.4 Epidural Vein Sealer Bipolar Electrocautery System (Medtronic Advanced Energy, Portsmouth, NH, USA) during endoscopic surgery for tumors of the skull base with particular attention to ergonomic benefits and technical nuances.MethodsWe conducted a retrospective review of all patients undergoing endoscopic surgery for skull base tumors from September 2012 to June 2016 at our institution. All procedures used the Aquamantys® system. 45 cases were identified.ResultsSuccessful hemostasis was achieved in all cases with an average estimated blood loss (EBL) of 46 mL (Range 10–250). There were no intraoperative complications. The single-shaft design allowed for excellent manipulation compared to pistol-grip bipolar forceps. The thermal energy provided excellent radial coverage without extensive penetration into viable pituitary tissue.ConclusionTo our knowledge, this is the largest series documenting the use of the Aquamantys® system in skull base surgery. The device is easily mobile and highly effective within the endonasal corridor and should be a tool in the repertoire of the endoneurosurgeon. Randomized control trials would be useful in comparing EBL between the Aquamantys® and standard bipolar electrocautery.     

颅底脊索瘤的显微外科治疗

目的 探讨脊索瘤的诊断及综合治疗。方法 对105例颅底脊索瘤作回顾性分析研究。结果手术108例次，有3例病人复发后再次行手术治疗。肿瘤全切除14例次，近全切除65例次，全切和次全切除率为73．2％，大部及部分切除29例次。手术死亡2例。108例次手术中有34例次术后出现并发症。结论 采用显微外科治疗方法，选择适当的手术入路，是提高肿瘤切除率，降低术后并发症是治疗的关键所在。     

单纯神经内镜下经单鼻腔-蝶窦入路手术治疗垂体腺瘤

目的 总结我科单纯神经内镜下经单鼻腔-蝶窦入路切除垂体腺瘤的手术经验,探讨该手术方式的优越性.方法 对经CT或MRI诊断为垂体腺瘤的42例患者(肿瘤直径<1cm11例,1～2 cm 11例,2～3cm 18例,>3cm 2例)采用经单鼻腔-蝶窦入路手术,术中不切除鼻中隔,直接打开蝶窦前壁,经鞍底切除垂体腺瘤.结果 全切除38例,次全切除4例.视力、视野均较术前有所恢复.6例术后出现一过性脑脊液漏,23例发生暂时性尿崩.术后18例内分泌检查恢复正常,4例随访激素水平下降.结论 单纯神经内镜下经单鼻腔蝶窦入路切除垂体腺瘤,具有手术创伤小、照明好、安全、提供360度全景的术野且并发症少.操作时间短,术后康复快等优点.该术式值得进一步推荐应用.     

New Landmark for the Endoscopic Endonasal Transsphenoidal Approach of Pituitary Surgery

Objective

To clarify the anatomical correlations of the sphenoid sinus with surrounding structures in the normal Korean population, and to identify surgical landmarks for safe sellar floor dissection in the anterior skull base by endoscopy and microscopy.

Methods

We reviewed the 196 brain magnetic resonance imaging findings showing a normal appearance, and measured the distances between anatomical landmarks.

Results

The mean distances from the base of the columella to the anterior wall of the sphenoid sinus and the sellar floor were 69.71±4.25 mm and 86.26±4.57 mm, respectively in the over 15 age group, and showed the smallest degree of variation among the measurements. The mean angles between the floor of the nasal cavity and the straight line connecting the base of the columella and the sellar floor were 29.45±3.25° and 24.75±4.00° in the over 15 and under 15 age groups, respectively. The mean values of both distances and angles increased with age until 15 years after which no further increases were evident. There were no significant differences in the measurements between males and females or among subjects with different degrees of pneumatization in the over 15 age group.

Conclusion

The distances from the base of the columella to the sellar floor and the anterior wall of the sphenoid sinus, which were consistent among individuals, could be used as a surgical indicator to investigate the sellar floor in endoscopic or microscopic transsphenoidal approaches.     

显微手术治疗颅底脑膜瘤23例分析

目的 探讨显微手术治疗颅底脑膜瘤的手术入路和操作要点.方法 选取本院收治行显微切除术的颅底脑膜瘤患者46例,随机分为观察组和对照组各23例;观察组以多螺旋CT和MRI对瘤体的解剖位置和血供走向作综合分析,分别选择额下、翼点、枕下等手术入路切除,对照组统一采取枕下乙状窦后入路;对比分析2组手术疗效,总结手术技巧.结果 除小脑桥脑角脑膜瘤外,观察组手术时间和术中出血量均显著少于对照组（P〈0.05）.观察组全切除19例,其中SimpsonⅠ级14例,SimpsonⅡ级5例,次全切除4例;对照组全切除12例,其中SimpsonⅠ级10例,SimpsonⅡ级2例,次全切除11例;观察组全切率显著高于对照组（P〈0.05）.观察组术后并发症发生率13.0%,显著显著低于对照组的43.8%（P〈0.05）.结论 颅底脑膜瘤解剖位置深,血供丰富,手术入路应以最大限度显露手术视野和最低程度减少脑组织牵拉为原则,尽可能接近颅底病变区域;在此基础上,精确掌握瘤体与周边组织的解剖关系,谨慎操作,避免医源性血管和神经损伤,是手术成功的关键.     

颅底软骨肉瘤

目的 提高对颅底软骨肉瘤的诊断和治疗水平。方法 总结分析9例颅底软骨肉瘤的临床经过，治疗和愈后。结果 手术全切除3例，次全切除1例，大部切除3例，部分切除2例。术后随访到5例，术后半年内死亡2例，1例术后9年复发再次手术，随访到首次术后15年。结论 颅底软骨肉瘤虽属颅内恶性肿瘤，如能早期发现，采取手术切除加放疗等综合治疗，部分病人仍可以获得较为满意的疗效。     

侵犯颅底及颌面部骨巨细胞瘤(附三例报道)

目的 探讨侵犯颅底及颌面部骨巨细胞瘤的诊断与手术治疗. 方法 对川北医学院附属医院神经外科自2001年3月至2009年4月收治的3例侵犯颅底及颌面部骨巨细胞瘤患者的临床资料进行回顾性分析,总结该病的诊断要点、鉴别诊断及手术治疗体会.3例患者肿瘤均位于中颅窝底,向外侵及颌面部,临床症状以颅神经症状和面容改变为主.CT及MRI提示病变呈膨胀、破坏性生长.3例患者均行手术治疗,2例患者术后行放射治疗. 结果 3例患者术后效果良好,术后病理证实均为骨巨细胞瘤.随访中1例患者肿瘤复发但生长缓慢,另一例未见明显复发. 结论 侵犯颅底及颌面部骨巨细胞瘤的诊断可根据其生长特点、其引起的颅神经症状及影像学特征来做出判断.手术是其治疗的首选方式,术后是否放疗仍存在争议.     

上颌骨翻转入路切除颅底沟通肿瘤的应用解剖

目的 探讨经上颌骨翻转入路切除颅内外沟通肿瘤可行性及其显微解部学关系.方法 (1)应用显微外科解剖技术,对经甲醛固定、动静脉血管内分别灌注红、蓝乳胶的10具(20侧)尸头标本,模拟手术入路逐层解剖,观察手术径路中颢下窝、翼腭窝、蝶筛区、海绵窦等区域的显露情况及重要解剖结构之间的关系.(2)经该手术入路切除颅底沟通肿瘤6例,回顾分析其临床资料.结果 翼突、中鼻甲、上颌神经是经上颌骨翻转手术入路的三个重要解剖标志,此入路对前、中颅底、斜坡区显露满意,有充足的手术操作空间,从颅外暴露颅底,对脑组织的牵拉损伤小.临床应用中,6例肿瘤均得到全切,术后反应小,恢复快.结论 上颌骨翻转入路切除颅内外沟通肿瘤手术可行,熟悉此入路的显微解剖学关系,对开展此手术入路切除颅底沟通肿瘤具有指导意义.     

上颌骨翻转入路切除颅底沟通肿瘤的应用解剖

目的 探讨经上颌骨翻转入路切除颅内外沟通肿瘤可行性及其显微解部学关系.方法 (1)应用显微外科解剖技术,对经甲醛固定、动静脉血管内分别灌注红、蓝乳胶的10具(20侧)尸头标本,模拟手术入路逐层解剖,观察手术径路中颢下窝、翼腭窝、蝶筛区、海绵窦等区域的显露情况及重要解剖结构之间的关系.(2)经该手术入路切除颅底沟通肿瘤6例,回顾分析其临床资料.结果 翼突、中鼻甲、上颌神经是经上颌骨翻转手术入路的三个重要解剖标志,此入路对前、中颅底、斜坡区显露满意,有充足的手术操作空间,从颅外暴露颅底,对脑组织的牵拉损伤小.临床应用中,6例肿瘤均得到全切,术后反应小,恢复快.结论 上颌骨翻转入路切除颅内外沟通肿瘤手术可行,熟悉此入路的显微解剖学关系,对开展此手术入路切除颅底沟通肿瘤具有指导意义.     

上颌骨翻转入路切除颅底沟通肿瘤的应用解剖

目的 探讨经上颌骨翻转入路切除颅内外沟通肿瘤可行性及其显微解部学关系.方法 (1)应用显微外科解剖技术,对经甲醛固定、动静脉血管内分别灌注红、蓝乳胶的10具(20侧)尸头标本,模拟手术入路逐层解剖,观察手术径路中颢下窝、翼腭窝、蝶筛区、海绵窦等区域的显露情况及重要解剖结构之间的关系.(2)经该手术入路切除颅底沟通肿瘤6例,回顾分析其临床资料.结果 翼突、中鼻甲、上颌神经是经上颌骨翻转手术入路的三个重要解剖标志,此入路对前、中颅底、斜坡区显露满意,有充足的手术操作空间,从颅外暴露颅底,对脑组织的牵拉损伤小.临床应用中,6例肿瘤均得到全切,术后反应小,恢复快.结论 上颌骨翻转入路切除颅内外沟通肿瘤手术可行,熟悉此入路的显微解剖学关系,对开展此手术入路切除颅底沟通肿瘤具有指导意义.     

上颌骨翻转入路切除颅底沟通肿瘤的应用解剖

目的 探讨经上颌骨翻转入路切除颅内外沟通肿瘤可行性及其显微解部学关系.方法 (1)应用显微外科解剖技术,对经甲醛固定、动静脉血管内分别灌注红、蓝乳胶的10具(20侧)尸头标本,模拟手术入路逐层解剖,观察手术径路中颢下窝、翼腭窝、蝶筛区、海绵窦等区域的显露情况及重要解剖结构之间的关系.(2)经该手术入路切除颅底沟通肿瘤6例,回顾分析其临床资料.结果 翼突、中鼻甲、上颌神经是经上颌骨翻转手术入路的三个重要解剖标志,此入路对前、中颅底、斜坡区显露满意,有充足的手术操作空间,从颅外暴露颅底,对脑组织的牵拉损伤小.临床应用中,6例肿瘤均得到全切,术后反应小,恢复快.结论 上颌骨翻转入路切除颅内外沟通肿瘤手术可行,熟悉此入路的显微解剖学关系,对开展此手术入路切除颅底沟通肿瘤具有指导意义.     

Significance of the simultaneous combined transcranial and endoscopic endonasal approach for prevention of postoperative CSF leak after surgery for lateral skull base meningioma

Lateral skull base meningiomas, particularly sphenoorbital meningiomas, sometimes extend extremely widely into adjacent structures including the paranasal sinuses. For endonasal skull base reconstruction using a vascularized nasoseptal flap for prevention of postoperative cerebrospinal fluid (CSF) leak, the simultaneous combined transcranial and endoscopic endonasal approach was applied for resection of these extensive tumors. We performed a retrospective review of four patients treated with the simultaneous combined transcranial and endoscopic endonasal approach for resection of lateral skull base meningiomas. Preoperative characteristics, tumor extent, extent of resection, complications, and postoperative outcomes were analyzed. The tumor extended into the paranasal sinus, infratemporal fossa, and pterygopalatine fossa in all patients. Extracranial extension into the cavernous sinus or superior orbital fissure was detected in two and three patients, respectively. In one patient without extension into the cavernous sinus and superior orbital fissure, gross total resection was achieved, whereas in the other three patients, subtotal resection was performed, and small residual masses of the tumor remained in the cavernous sinus or superior orbital fissure to minimize the risk of postoperative ocular nerve damage. No patients experienced postoperative CSF leak. The simultaneous combined transcranial and endoscopic endonasal approach is useful for a subgroup of patients with lateral skull base meningiomas for prevention of postoperative CSF leak. Particularly in recurrent cases in which vascularized flaps from the transcranial side are likely unavailable due to prior tumor resection, this combined approach is worth considering depending on tumor extension into the paranasal sinus.     

上颌骨翻转入路切除颅底沟通肿瘤的应用解剖

目的 探讨经上颌骨翻转入路切除颅内外沟通肿瘤可行性及其显微解部学关系.方法 (1)应用显微外科解剖技术,对经甲醛固定、动静脉血管内分别灌注红、蓝乳胶的10具(20侧)尸头标本,模拟手术入路逐层解剖,观察手术径路中颢下窝、翼腭窝、蝶筛区、海绵窦等区域的显露情况及重要解剖结构之间的关系.(2)经该手术入路切除颅底沟通肿瘤6例,回顾分析其临床资料.结果 翼突、中鼻甲、上颌神经是经上颌骨翻转手术入路的三个重要解剖标志,此入路对前、中颅底、斜坡区显露满意,有充足的手术操作空间,从颅外暴露颅底,对脑组织的牵拉损伤小.临床应用中,6例肿瘤均得到全切,术后反应小,恢复快.结论 上颌骨翻转入路切除颅内外沟通肿瘤手术可行,熟悉此入路的显微解剖学关系,对开展此手术入路切除颅底沟通肿瘤具有指导意义.