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Paul A Gardner - One of the best experts on this subject based on the ideXlab platform.
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nasopharyngeal muscle patch for the management of internal carotid artery injury in Endoscopic Endonasal Surgery
Journal of Neurosurgery, 2019Co-Authors: Weihsin Wang, Juan C Fernandezmiranda, Carl H Snyderman, Eric W Wang, Stefan Lieber, Mingying Lan, Paul A GardnerAbstract:OBJECTIVE Injury to the internal carotid artery (ICA) is the most critical complication of Endoscopic Endonasal skull base Surgery. Packing with a crushed muscle graft at the injury site has been an effective management technique to control bleeding without ICA sacrifice. Obtaining the muscle graft has typically required access to another surgical site, however. To address this concern, the authors investigated the application of an Endonasally harvested longus capitis muscle patch for the management of ICA injury. METHODS One colored silicone-injected anatomical specimen was dissected to replicate the surgical access to the nasopharynx and the stepwise dissection of the longus capitis muscle in the nasopharynx. Two representative cases were selected to illustrate the application of the longus capitis muscle patch and the relevance of clinical considerations. RESULTS A suitable muscle graft from the longus capitis muscle could be easily and quickly harvested during Endoscopic Endonasal skull base Surgery. In the illustrative cases, the longus capitis muscle patch was successfully used for secondary prevention of pseudoaneurysm formation following primary bleeding control on the site of ICA injury. CONCLUSIONS Nasopharyngeal harvest of a longus capitis muscle graft is a safe and practical method to manage ICA injury during Endoscopic Endonasal Surgery.
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Stepwise Algorithm for Skull Base Reconstruction in Endoscopic Endonasal Surgery: From the Simple to the Complex
Neurosurgery, 2019Co-Authors: Maria Belen Vega, Carl H Snyderman, Eric W Wang, Philippe Lavigne, Vanessa Hernandez-hernandez, Aldo Eguiluz-menendez, Paul A GardnerAbstract:Abstract INTRODUCTION The most frequent complication of Endoscopic Endonasal Surgery (EES) is postoperative cerebrospinal fluid (CSF) leak. This study was designed to develop a step-wise algorithm for EES reconstruction across the spectrum of skull base defects: from free mucosal graft for uncomplicated pituitary adenomas to free flaps in complex cases with recurrent leaks. METHODS All patients with skull base pathologies who underwent EES between January 2017 and December 2018 were included and retrospectively analyzed. Tumor location, reconstruction method and postoperative CSF leak were reviewed and a step-wise algorithm based on size and location of defect was developed. RESULTS Location of skull base defects was categorized as follows: anterior fossa, suprasellar, sellar and posterior fossa. For all nonsellar sites, we performed a multilayer (collagen matrix + /- fascia lata + /− fat graft + vascularized flap) reconstruction. The nasoseptal flap (NSF) was the first choice for vascularized reconstruction when available. For all sellar lesions we employed a free mucosal graft unless a high-flow CSF leak was present, in which case a single-layer reconstruction with NSF was performed. When the NSF was not available, alternative local (lateral nasal wall flap) and regional (extracranial pericranial flap) pedicled flaps were successful choices. When patients failed multiple attempts at repair, regional or microvascular free flaps were options. Lumbar spinal drainage was employed for large anterior and posterior fossa defects and during secondary repair of postoperative CSF leaks. Of 347 patients, 4.6% had a postoperative CSF leak. Of 158 patients with an intraoperative leak (45.5%), 10.1% developed a postoperative CSF leak: 7.8% for sellar/suprasellar defects and 13% for anterior/posterior fossa defects. CONCLUSION This algorithm provides a standardized, stepwise approach to the reconstruction of all skull base defects after EES based on location.
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Validation of training levels in Endoscopic Endonasal Surgery of the skull base.
Laryngoscope, 2019Co-Authors: Philippe Lavigne, Juan Carlos Fernandez-miranda, Paul A Gardner, Eric W Wang, Daniel L. Faden, Carl H SnydermanAbstract:OBJECTIVE: A five-level training program was first proposed 10 years ago for surgeons learning Endoscopic Endonasal Surgery (EES) of the skull base. Levels were based on the complexity of anatomy, risk of neurovascular injury, intradural dissection, technical difficulty and vascularity of tumors. METHOD: A three-phase validation concept is proposed: 1) face validity (the classification is related to clinically significant elements), 2) construct validity (the classification predicts the outcome), and 3) inter-team validation (the classification applies to other surgical teams). Consecutive cases over a 1-year time span were retrospectively classified. Primary outcome measures included: complication rates (cranial nerve injury, stroke and vascular injury, cerebrospinal fluid [CSF] leak and infection), estimated blood loss and duration of Surgery. RESULTS: Two hundred and nine consecutive cases were analyzed. The distribution of cases for each category was: 63 cases in level II, 70 cases in level III, 66 cases in level IV, and 10 cases in level V. Construct validity demonstrated statistical difference with increasing rate of complications from level II to level III and from level III to level IV; also, specific rates of cranial nerve injury and CSF leak increased between levels III and IV. Face validity identified 162 citations since publication of the original article. Inter-team validation demonstrated no difference between two teams of surgeons. CONCLUSION: This study provides a three-phase validation of training levels for Endoscopic skull base Surgery. Adoption of a progressive systematic approach to learning EES from least complex to advanced procedures is expected to minimize the risks while surgical teams gain experience. LEVEL OF EVIDENCE: 3 Laryngoscope, 129:2253-2257, 2019.
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Endoscopic Endonasal Surgery for epidermoid and dermoid cysts: a 10-year experience.
Journal of neurosurgery, 2018Co-Authors: Francisco Vaz-guimaraes, Maria Koutourousiou, Carl H Snyderman, Eric W Wang, Juan C. Fernandez-miranda, John R. De Almeida, Elizabeth C. Tyler-kabara, Paul A GardnerAbstract:OBJECTIVEEpidermoid and dermoid cysts may be found along the cranial base and are commonly resected via open transcranial approaches. The use of Endoscopic Endonasal approaches for resection of these tumors has been rarely reported.METHODSThe authors retrospectively reviewed the medical records of 21 patients who underwent Endoscopic Endonasal Surgery for epidermoid and dermoid cyst resection at the University of Pittsburgh Medical Center between January 2005 and June 2014. Surgical outcomes and variables that might affect the extent of resection and complications were analyzed.RESULTSTotal resection (total removal of cyst contents and capsule) was achieved in 8 patients (38.1%), near-total resection (total removal of cyst contents, incomplete removal of cyst capsule) in 9 patients (42.9%), and subtotal resection (incomplete removal of cyst contents and capsule) in 4 patients (19%). Larger cyst volume (≥ 3 cm3) and intradural location (15 cysts) were significantly associated with nontotal resection (p = 0...
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Iatrogenic seeding of skull base chordoma following Endoscopic Endonasal Surgery.
Journal of neurosurgery, 2017Co-Authors: David T. Fernandes Cabral, Eric W Wang, Georgios A. Zenonos, Juan C. Fernandez-miranda, Paul A GardnerAbstract:OBJECTIVEIatrogenic tumor seeding after open Surgery for chordoma has been well described in the literature. The incidence and particularities related to Endoscopic Endonasal Surgery (EES) have not been defined.METHODSThe authors retrospectively reviewed their experience with EES for clival chordoma, focusing on cases with iatrogenic seeding. The clinical, radiographic, pathological, and molecular characterization data were reviewed.RESULTSAmong 173 EESs performed for clival chordomas at the authors’ institution between April 2003 and May 2016, 2 cases complicated by iatrogenic seeding (incidence 1.15%) were identified. The first case was a 10-year-old boy, who presented 21 months after an EES for a multiply recurrent clival chordoma with a recurrence along the left inferior turbinate, distinct from a right petrous apex recurrence. Both appeared as a T2-hypertintense, T1-isointense, and heterogeneously enhancing lesion on MRI. Resection of the inferior turbinate recurrence and debulking of the petrous rec...
Carl H Snyderman - One of the best experts on this subject based on the ideXlab platform.
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nasopharyngeal muscle patch for the management of internal carotid artery injury in Endoscopic Endonasal Surgery
Journal of Neurosurgery, 2019Co-Authors: Weihsin Wang, Juan C Fernandezmiranda, Carl H Snyderman, Eric W Wang, Stefan Lieber, Mingying Lan, Paul A GardnerAbstract:OBJECTIVE Injury to the internal carotid artery (ICA) is the most critical complication of Endoscopic Endonasal skull base Surgery. Packing with a crushed muscle graft at the injury site has been an effective management technique to control bleeding without ICA sacrifice. Obtaining the muscle graft has typically required access to another surgical site, however. To address this concern, the authors investigated the application of an Endonasally harvested longus capitis muscle patch for the management of ICA injury. METHODS One colored silicone-injected anatomical specimen was dissected to replicate the surgical access to the nasopharynx and the stepwise dissection of the longus capitis muscle in the nasopharynx. Two representative cases were selected to illustrate the application of the longus capitis muscle patch and the relevance of clinical considerations. RESULTS A suitable muscle graft from the longus capitis muscle could be easily and quickly harvested during Endoscopic Endonasal skull base Surgery. In the illustrative cases, the longus capitis muscle patch was successfully used for secondary prevention of pseudoaneurysm formation following primary bleeding control on the site of ICA injury. CONCLUSIONS Nasopharyngeal harvest of a longus capitis muscle graft is a safe and practical method to manage ICA injury during Endoscopic Endonasal Surgery.
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Stepwise Algorithm for Skull Base Reconstruction in Endoscopic Endonasal Surgery: From the Simple to the Complex
Neurosurgery, 2019Co-Authors: Maria Belen Vega, Carl H Snyderman, Eric W Wang, Philippe Lavigne, Vanessa Hernandez-hernandez, Aldo Eguiluz-menendez, Paul A GardnerAbstract:Abstract INTRODUCTION The most frequent complication of Endoscopic Endonasal Surgery (EES) is postoperative cerebrospinal fluid (CSF) leak. This study was designed to develop a step-wise algorithm for EES reconstruction across the spectrum of skull base defects: from free mucosal graft for uncomplicated pituitary adenomas to free flaps in complex cases with recurrent leaks. METHODS All patients with skull base pathologies who underwent EES between January 2017 and December 2018 were included and retrospectively analyzed. Tumor location, reconstruction method and postoperative CSF leak were reviewed and a step-wise algorithm based on size and location of defect was developed. RESULTS Location of skull base defects was categorized as follows: anterior fossa, suprasellar, sellar and posterior fossa. For all nonsellar sites, we performed a multilayer (collagen matrix + /- fascia lata + /− fat graft + vascularized flap) reconstruction. The nasoseptal flap (NSF) was the first choice for vascularized reconstruction when available. For all sellar lesions we employed a free mucosal graft unless a high-flow CSF leak was present, in which case a single-layer reconstruction with NSF was performed. When the NSF was not available, alternative local (lateral nasal wall flap) and regional (extracranial pericranial flap) pedicled flaps were successful choices. When patients failed multiple attempts at repair, regional or microvascular free flaps were options. Lumbar spinal drainage was employed for large anterior and posterior fossa defects and during secondary repair of postoperative CSF leaks. Of 347 patients, 4.6% had a postoperative CSF leak. Of 158 patients with an intraoperative leak (45.5%), 10.1% developed a postoperative CSF leak: 7.8% for sellar/suprasellar defects and 13% for anterior/posterior fossa defects. CONCLUSION This algorithm provides a standardized, stepwise approach to the reconstruction of all skull base defects after EES based on location.
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Validation of training levels in Endoscopic Endonasal Surgery of the skull base.
Laryngoscope, 2019Co-Authors: Philippe Lavigne, Juan Carlos Fernandez-miranda, Paul A Gardner, Eric W Wang, Daniel L. Faden, Carl H SnydermanAbstract:OBJECTIVE: A five-level training program was first proposed 10 years ago for surgeons learning Endoscopic Endonasal Surgery (EES) of the skull base. Levels were based on the complexity of anatomy, risk of neurovascular injury, intradural dissection, technical difficulty and vascularity of tumors. METHOD: A three-phase validation concept is proposed: 1) face validity (the classification is related to clinically significant elements), 2) construct validity (the classification predicts the outcome), and 3) inter-team validation (the classification applies to other surgical teams). Consecutive cases over a 1-year time span were retrospectively classified. Primary outcome measures included: complication rates (cranial nerve injury, stroke and vascular injury, cerebrospinal fluid [CSF] leak and infection), estimated blood loss and duration of Surgery. RESULTS: Two hundred and nine consecutive cases were analyzed. The distribution of cases for each category was: 63 cases in level II, 70 cases in level III, 66 cases in level IV, and 10 cases in level V. Construct validity demonstrated statistical difference with increasing rate of complications from level II to level III and from level III to level IV; also, specific rates of cranial nerve injury and CSF leak increased between levels III and IV. Face validity identified 162 citations since publication of the original article. Inter-team validation demonstrated no difference between two teams of surgeons. CONCLUSION: This study provides a three-phase validation of training levels for Endoscopic skull base Surgery. Adoption of a progressive systematic approach to learning EES from least complex to advanced procedures is expected to minimize the risks while surgical teams gain experience. LEVEL OF EVIDENCE: 3 Laryngoscope, 129:2253-2257, 2019.
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Endoscopic Endonasal Surgery for epidermoid and dermoid cysts: a 10-year experience.
Journal of neurosurgery, 2018Co-Authors: Francisco Vaz-guimaraes, Maria Koutourousiou, Carl H Snyderman, Eric W Wang, Juan C. Fernandez-miranda, John R. De Almeida, Elizabeth C. Tyler-kabara, Paul A GardnerAbstract:OBJECTIVEEpidermoid and dermoid cysts may be found along the cranial base and are commonly resected via open transcranial approaches. The use of Endoscopic Endonasal approaches for resection of these tumors has been rarely reported.METHODSThe authors retrospectively reviewed the medical records of 21 patients who underwent Endoscopic Endonasal Surgery for epidermoid and dermoid cyst resection at the University of Pittsburgh Medical Center between January 2005 and June 2014. Surgical outcomes and variables that might affect the extent of resection and complications were analyzed.RESULTSTotal resection (total removal of cyst contents and capsule) was achieved in 8 patients (38.1%), near-total resection (total removal of cyst contents, incomplete removal of cyst capsule) in 9 patients (42.9%), and subtotal resection (incomplete removal of cyst contents and capsule) in 4 patients (19%). Larger cyst volume (≥ 3 cm3) and intradural location (15 cysts) were significantly associated with nontotal resection (p = 0...
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injury of the carotid artery during Endoscopic Endonasal Surgery surveys of skull base surgeons
Skull Base Surgery, 2017Co-Authors: Nicholas R Rowan, Meghan T Turner, Benita Valappil, Juan C Fernandezmiranda, Paul A Gardner, Eric W Wang, Carl H SnydermanAbstract:Objectives This study aimed to review Endoscopic skull base surgeon experience with internal carotid artery (ICA) injuries during Endoscopic Endonasal Surgery (EES) to provide an estimate of the incidence of ICA injury, the associated factors and identify the best training modalities for the management of this complication. Design Anonymous electronic survey of past participants at a well-established Endoscopic skull base Surgery course and a global online community of skull base surgeons. Main Outcome Measures Relative incidence of ICA injuries during EES, associated anatomic and intraoperative factors, and surgeon experience. Results At least 20% of surgeons in each surveyed population experienced a carotid artery injury. Reported carotid artery injuries were most common during tumor exposure and removal (48%). The parasellar carotid artery was the most commonly injured segment (39%). Carotid artery injuries were more common in high-volume surgeons, but only statistically significant in one of the two populations. Attendance at a skull base course or courses did not change the incidence of carotid artery injury in either surveyed population. In both surveys, respondents preferred live surgeries or active (not computer simulated) training models. Conclusions ICA injury is underreported and most common when manipulating the parasellar carotid artery for exposure and tumor dissection. Given the high morbidity and mortality associated with these injuries, vascular injury management should be prioritized and taught in a graduated approach by modern Endoscopic skull base courses.
Eric W Wang - One of the best experts on this subject based on the ideXlab platform.
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nasopharyngeal muscle patch for the management of internal carotid artery injury in Endoscopic Endonasal Surgery
Journal of Neurosurgery, 2019Co-Authors: Weihsin Wang, Juan C Fernandezmiranda, Carl H Snyderman, Eric W Wang, Stefan Lieber, Mingying Lan, Paul A GardnerAbstract:OBJECTIVE Injury to the internal carotid artery (ICA) is the most critical complication of Endoscopic Endonasal skull base Surgery. Packing with a crushed muscle graft at the injury site has been an effective management technique to control bleeding without ICA sacrifice. Obtaining the muscle graft has typically required access to another surgical site, however. To address this concern, the authors investigated the application of an Endonasally harvested longus capitis muscle patch for the management of ICA injury. METHODS One colored silicone-injected anatomical specimen was dissected to replicate the surgical access to the nasopharynx and the stepwise dissection of the longus capitis muscle in the nasopharynx. Two representative cases were selected to illustrate the application of the longus capitis muscle patch and the relevance of clinical considerations. RESULTS A suitable muscle graft from the longus capitis muscle could be easily and quickly harvested during Endoscopic Endonasal skull base Surgery. In the illustrative cases, the longus capitis muscle patch was successfully used for secondary prevention of pseudoaneurysm formation following primary bleeding control on the site of ICA injury. CONCLUSIONS Nasopharyngeal harvest of a longus capitis muscle graft is a safe and practical method to manage ICA injury during Endoscopic Endonasal Surgery.
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Stepwise Algorithm for Skull Base Reconstruction in Endoscopic Endonasal Surgery: From the Simple to the Complex
Neurosurgery, 2019Co-Authors: Maria Belen Vega, Carl H Snyderman, Eric W Wang, Philippe Lavigne, Vanessa Hernandez-hernandez, Aldo Eguiluz-menendez, Paul A GardnerAbstract:Abstract INTRODUCTION The most frequent complication of Endoscopic Endonasal Surgery (EES) is postoperative cerebrospinal fluid (CSF) leak. This study was designed to develop a step-wise algorithm for EES reconstruction across the spectrum of skull base defects: from free mucosal graft for uncomplicated pituitary adenomas to free flaps in complex cases with recurrent leaks. METHODS All patients with skull base pathologies who underwent EES between January 2017 and December 2018 were included and retrospectively analyzed. Tumor location, reconstruction method and postoperative CSF leak were reviewed and a step-wise algorithm based on size and location of defect was developed. RESULTS Location of skull base defects was categorized as follows: anterior fossa, suprasellar, sellar and posterior fossa. For all nonsellar sites, we performed a multilayer (collagen matrix + /- fascia lata + /− fat graft + vascularized flap) reconstruction. The nasoseptal flap (NSF) was the first choice for vascularized reconstruction when available. For all sellar lesions we employed a free mucosal graft unless a high-flow CSF leak was present, in which case a single-layer reconstruction with NSF was performed. When the NSF was not available, alternative local (lateral nasal wall flap) and regional (extracranial pericranial flap) pedicled flaps were successful choices. When patients failed multiple attempts at repair, regional or microvascular free flaps were options. Lumbar spinal drainage was employed for large anterior and posterior fossa defects and during secondary repair of postoperative CSF leaks. Of 347 patients, 4.6% had a postoperative CSF leak. Of 158 patients with an intraoperative leak (45.5%), 10.1% developed a postoperative CSF leak: 7.8% for sellar/suprasellar defects and 13% for anterior/posterior fossa defects. CONCLUSION This algorithm provides a standardized, stepwise approach to the reconstruction of all skull base defects after EES based on location.
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Validation of training levels in Endoscopic Endonasal Surgery of the skull base.
Laryngoscope, 2019Co-Authors: Philippe Lavigne, Juan Carlos Fernandez-miranda, Paul A Gardner, Eric W Wang, Daniel L. Faden, Carl H SnydermanAbstract:OBJECTIVE: A five-level training program was first proposed 10 years ago for surgeons learning Endoscopic Endonasal Surgery (EES) of the skull base. Levels were based on the complexity of anatomy, risk of neurovascular injury, intradural dissection, technical difficulty and vascularity of tumors. METHOD: A three-phase validation concept is proposed: 1) face validity (the classification is related to clinically significant elements), 2) construct validity (the classification predicts the outcome), and 3) inter-team validation (the classification applies to other surgical teams). Consecutive cases over a 1-year time span were retrospectively classified. Primary outcome measures included: complication rates (cranial nerve injury, stroke and vascular injury, cerebrospinal fluid [CSF] leak and infection), estimated blood loss and duration of Surgery. RESULTS: Two hundred and nine consecutive cases were analyzed. The distribution of cases for each category was: 63 cases in level II, 70 cases in level III, 66 cases in level IV, and 10 cases in level V. Construct validity demonstrated statistical difference with increasing rate of complications from level II to level III and from level III to level IV; also, specific rates of cranial nerve injury and CSF leak increased between levels III and IV. Face validity identified 162 citations since publication of the original article. Inter-team validation demonstrated no difference between two teams of surgeons. CONCLUSION: This study provides a three-phase validation of training levels for Endoscopic skull base Surgery. Adoption of a progressive systematic approach to learning EES from least complex to advanced procedures is expected to minimize the risks while surgical teams gain experience. LEVEL OF EVIDENCE: 3 Laryngoscope, 129:2253-2257, 2019.
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Endoscopic Endonasal Surgery for epidermoid and dermoid cysts: a 10-year experience.
Journal of neurosurgery, 2018Co-Authors: Francisco Vaz-guimaraes, Maria Koutourousiou, Carl H Snyderman, Eric W Wang, Juan C. Fernandez-miranda, John R. De Almeida, Elizabeth C. Tyler-kabara, Paul A GardnerAbstract:OBJECTIVEEpidermoid and dermoid cysts may be found along the cranial base and are commonly resected via open transcranial approaches. The use of Endoscopic Endonasal approaches for resection of these tumors has been rarely reported.METHODSThe authors retrospectively reviewed the medical records of 21 patients who underwent Endoscopic Endonasal Surgery for epidermoid and dermoid cyst resection at the University of Pittsburgh Medical Center between January 2005 and June 2014. Surgical outcomes and variables that might affect the extent of resection and complications were analyzed.RESULTSTotal resection (total removal of cyst contents and capsule) was achieved in 8 patients (38.1%), near-total resection (total removal of cyst contents, incomplete removal of cyst capsule) in 9 patients (42.9%), and subtotal resection (incomplete removal of cyst contents and capsule) in 4 patients (19%). Larger cyst volume (≥ 3 cm3) and intradural location (15 cysts) were significantly associated with nontotal resection (p = 0...
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Iatrogenic seeding of skull base chordoma following Endoscopic Endonasal Surgery.
Journal of neurosurgery, 2017Co-Authors: David T. Fernandes Cabral, Eric W Wang, Georgios A. Zenonos, Juan C. Fernandez-miranda, Paul A GardnerAbstract:OBJECTIVEIatrogenic tumor seeding after open Surgery for chordoma has been well described in the literature. The incidence and particularities related to Endoscopic Endonasal Surgery (EES) have not been defined.METHODSThe authors retrospectively reviewed their experience with EES for clival chordoma, focusing on cases with iatrogenic seeding. The clinical, radiographic, pathological, and molecular characterization data were reviewed.RESULTSAmong 173 EESs performed for clival chordomas at the authors’ institution between April 2003 and May 2016, 2 cases complicated by iatrogenic seeding (incidence 1.15%) were identified. The first case was a 10-year-old boy, who presented 21 months after an EES for a multiply recurrent clival chordoma with a recurrence along the left inferior turbinate, distinct from a right petrous apex recurrence. Both appeared as a T2-hypertintense, T1-isointense, and heterogeneously enhancing lesion on MRI. Resection of the inferior turbinate recurrence and debulking of the petrous rec...
Maria Koutourousiou - One of the best experts on this subject based on the ideXlab platform.
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Endoscopic Endonasal Surgery for epidermoid and dermoid cysts: a 10-year experience.
Journal of neurosurgery, 2018Co-Authors: Francisco Vaz-guimaraes, Maria Koutourousiou, Carl H Snyderman, Eric W Wang, Juan C. Fernandez-miranda, John R. De Almeida, Elizabeth C. Tyler-kabara, Paul A GardnerAbstract:OBJECTIVEEpidermoid and dermoid cysts may be found along the cranial base and are commonly resected via open transcranial approaches. The use of Endoscopic Endonasal approaches for resection of these tumors has been rarely reported.METHODSThe authors retrospectively reviewed the medical records of 21 patients who underwent Endoscopic Endonasal Surgery for epidermoid and dermoid cyst resection at the University of Pittsburgh Medical Center between January 2005 and June 2014. Surgical outcomes and variables that might affect the extent of resection and complications were analyzed.RESULTSTotal resection (total removal of cyst contents and capsule) was achieved in 8 patients (38.1%), near-total resection (total removal of cyst contents, incomplete removal of cyst capsule) in 9 patients (42.9%), and subtotal resection (incomplete removal of cyst contents and capsule) in 4 patients (19%). Larger cyst volume (≥ 3 cm3) and intradural location (15 cysts) were significantly associated with nontotal resection (p = 0...
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Endoscopic Endonasal Surgery for Tumors of the Cavernous Sinus: A Series of 234 Patients
World neurosurgery, 2017Co-Authors: Maria Koutourousiou, Carl H Snyderman, Eric W Wang, Juan C. Fernandez-miranda, Francisco Vaz Guimaraes Filho, Susan T. Stefko, Paul A GardnerAbstract:Background Cavernous sinus (CS) tumors often are considered inoperable. We present our experience with Endoscopic Endonasal Surgery (EES) and compare the outcomes for different tumor. Methods EES (medial or lateral approach) was used in 234 patients with CS tumors. The cohort included 175 (75%) pituitary adenomas and 59 (25%) nonadenomatous lesions. Results Presenting symptoms were significantly different between the 2 groups, with cranial neuropathies occurring mainly in nonadenomas (P Conclusions EES provides an easily accessible midline corridor to the CS with equivalent or superior results to transcranial approaches in the management of select tumors. Symptomatology due to CS invasion is more likely to improve in pituitary adenomas and the rate of surgical complications is greater in nonadenomas. Using a team approach, the overall mortality due to vascular injury is low.
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Cerebral Vasospasms Following Endoscopic Endonasal Surgery for Pituitary Adenoma Resection in the Absence of Post-Operative Subarachnoid Hemorrhage
Journal of Neurology & Stroke, 2016Co-Authors: Paul S. Page, Daniel D Kim, Graham C Hall, Maria KoutourousiouAbstract:The Endoscopic Endonasal approach (EEA) is a widely accepted and commonly utilized approach for the resection of various pituitary tumors. While complications commonly include diabetes insipidus, cerebrospinal fluid leaks, and anterior lobe insufficiency cerebral vasospasm may also rarely occur. Herein, we report the unique case of a 44-year-old female who underwent uncomplicated Endoscopic Endonasal Surgery for resection of a giant pituitary adenoma. Subsequent cerebral vasospasms were identified on postoperative day 3 and 19 resulting in ischemic strokes with neurological consequence. In the postoperative period, imaging at no point revealed any evidence of subarachnoid hemorrhage or hematoma formation in the subarachnoid space. Risk factors for cerebral vasospasm are discussed and the potential for subsequent vasospasm events is addressed.
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pontine encephalocele and abnormalities of the posterior fossa following transclival Endoscopic Endonasal Surgery
Journal of Neurosurgery, 2014Co-Authors: Maria Koutourousiou, Juan C Fernandezmiranda, Carl H Snyderman, Eric W Wang, Francisco Vaz Guimaraes Filho, Tina Costacou, William E Rothfus, Paul A GardnerAbstract:Object Transclival Endoscopic Endonasal Surgery (EES) has recently been used for the treatment of posterior fossa tumors. The optimal method of reconstruction of large clival defects following EES has not been established. Methods A morphometric analysis of the posterior fossa was performed in patients who underwent transclival EES to compare those with observed postoperative anatomical changes (study group) to 50 normal individuals (anatomical control group) and 41 matched transclival cases with preserved posterior fossa anatomy (case-control group) using the same parameters. Given the absence of clival bone following transclival EES, the authors used the line between the anterior commissure and the basion as an equivalent to the clival plane to evaluate the location of the pons. Four parameters were studied and compared in the two populations: the pontine location/displacement, the maximum anteroposterior (AP) diameter of the pons, the maximum AP diameter of the fourth ventricle, and the cervicomedullar...
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Endoscopic Endonasal Surgery for Suprasellar Meningiomas: Experience with 75 Cases
Journal of Neurological Surgery Part B: Skull Base, 2014Co-Authors: Maria Koutourousiou, Juan Carlos Fernandez-miranda, Carl H Snyderman, E. W. Wang, Paul A GardnerAbstract:Object Following the introduction of the neurosurgical microscope, the outcomes in suprasellar meningioma Surgery were dramatically improved. More recently, the neurosurgical endoscope has been introduced as a visualization option during removal of skull base tumors, both transcranially and Endonasally. The authors retrospectively reviewed the effectiveness of Endoscopic Endonasal Surgery (EES) in the management of suprasellar meningiomas. Methods Between 2002 and 2011, 75 patients (81.3% female) with suprasellar meningiomas underwent EES at the University of Pittsburgh Medical Center. The authors present the results of EES and analyze the resection rates, visual outcome, and complications. Results Seventy-one patients presented with primary tumors, whereas 4 were previously treated elsewhere. Their mean age was 57.3 years (range 36–88 years), and most patients presented with visual loss (81.3%). Tumors occupied the tuberculum sellae (86.7%) and planum sphenoidale (50.7%), with extension into the optic ca...
Fred Gentili - One of the best experts on this subject based on the ideXlab platform.
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Endoscopic Endonasal Surgery in recurrent and residual pituitary adenomas after microscopic resection
World Neurosurgery, 2012Co-Authors: Hussein Alahmadi, Amir R Dehdashti, Fred GentiliAbstract:Background Despite the increasing interest in Endoscopic techniques for pituitary Surgery, little has been published on the Endoscopic approach for recurrent and/or residual pituitary adenomas. We report the outcome of purely Endoscopic Endonasal Surgery for a series of recurrent and/or residual pituitary tumors after a previous microscopic resection. Methods We reviewed all of the patients in our institution who underwent Endoscopic resection for recurrent and/or residual pituitary tumors after previous microscopic resection. All patients had clinical and magnetic resonance imaging follow-up of at least 3 months postoperatively. Careful attention was given to the operative reports documenting the degree of previous microscopic exposure. Our results were compared with published reports of Surgery for recurrent and residual pituitary tumors. Results Thirty-nine patients met our inclusion criteria. The mean follow-up was 21 months. Tumors were comprised of 19 nonfunctional, 10 adrenocorticotropic hormone, 9 growth hormone, and 1 prolactin-secreting adenoma. The Endoscopic procedure revealed limited previous exposure of the sphenoidal and sellar structures in 30 cases (76%). Sphenoidotomy and sellar opening, in terms of working area and angle of view, were significantly restricted in 64% and 61% of the cases, respectively. Gross total removal was achieved in 46% of cases. Seventeen patients had frank cavernous sinus invasion. Conclusions The restricted exposure of sphenoidal and sellar structures by the microscopic approach may be a contributing factor to incomplete tumor resection. The results observed in this setting make the Endoscopic technique a valid option in recurrent and residual pituitary adenomas treated initially by microscopic Surgery.
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Endoscopic Endonasal Surgery in recurrent and residual pituitary adenomas after microscopic resection.
World neurosurgery, 2011Co-Authors: Hussein Alahmadi, Amir R Dehdashti, Fred GentiliAbstract:Despite the increasing interest in Endoscopic techniques for pituitary Surgery, little has been published on the Endoscopic approach for recurrent and/or residual pituitary adenomas. We report the outcome of purely Endoscopic Endonasal Surgery for a series of recurrent and/or residual pituitary tumors after a previous microscopic resection. We reviewed all of the patients in our institution who underwent Endoscopic resection for recurrent and/or residual pituitary tumors after previous microscopic resection. All patients had clinical and magnetic resonance imaging follow-up of at least 3 months postoperatively. Careful attention was given to the operative reports documenting the degree of previous microscopic exposure. Our results were compared with published reports of Surgery for recurrent and residual pituitary tumors. Thirty-nine patients met our inclusion criteria. The mean follow-up was 21 months. Tumors were comprised of 19 nonfunctional, 10 adrenocorticotropic hormone, 9 growth hormone, and 1 prolactin-secreting adenoma. The Endoscopic procedure revealed limited previous exposure of the sphenoidal and sellar structures in 30 cases (76%). Sphenoidotomy and sellar opening, in terms of working area and angle of view, were significantly restricted in 64% and 61% of the cases, respectively. Gross total removal was achieved in 46% of cases. Seventeen patients had frank cavernous sinus invasion. The restricted exposure of sphenoidal and sellar structures by the microscopic approach may be a contributing factor to incomplete tumor resection. The results observed in this setting make the Endoscopic technique a valid option in recurrent and residual pituitary adenomas treated initially by microscopic Surgery. Copyright © 2012 Elsevier Inc. All rights reserved.