Original ArticleThe Radiographic Effects of Surgical Approach and Use of Retractors on the Brain After Anterior Cranial Fossa Meningioma Resection
Introduction
The goal of intracranial surgery is to remove the disease with as little impact on the surrounding structures as possible.1, 2 This ability to minimize collateral damage is especially difficult for deep-seated tumors.1, 2, 3 For deep-seated tumors, fixed retractor systems have historically been used to facilitate the displacement of the brain to allow access to intracranial locations, including skull base (SB) tumors.4 With advancements in imaging and surgical techniques, there is an increasing trend toward obviating the use of fixed retractors and instead relying on SB approaches and dynamic retraction or retractorless surgery.2 The premise of various SB approaches is to increase the working corridor by removing bone to avoid brain manipulation because fixed retraction on the brain, especially for prolonged periods, can lead to tissue ischemia, injury, and edema.5, 6, 7, 8, 9 However, this evaluation has been limited primarily to animal studies.5, 6, 7, 8, 9 The clinical impact of SB approaches and fixed retractors on the brain remains unclear.
Anterior SB meningiomas, namely those arising from the olfactory groove, planum sphenoidale, and tuberculum sella, are tumors in which resection can be achieved with and without SB approaches and/or fixed retraction. These tumors often present later than other tumors and can reach larger sizes and develop significant vasogenic edema.10, 11, 12 The goal of this study is to evaluate the effects of SB approaches and retractor-assisted (RA) surgery on fluid-attenuated inversion recovery (FLAIR) changes in the brain over time. This understanding may help guide surgical strategy aimed at minimizing the potential collateral damage caused by surgery.
Section snippets
Patient Selection
Institutional review board approval was obtained before the start of this study (72892). All adult patients (age >18 years) undergoing primary resection of an anterior cranial fossa World Health Organization (WHO) grade I meningioma (olfactory groove, planum sphenoidal, tuberulum sella, and clinoid) through a craniotomy at a single academic tertiary-care institution between 2010 and 2015 were retrospectively reviewed. Tumor location was based on preoperative radiology reports and on the
Patient Population
The preoperative, perioperative, and postoperative characteristics of the 136 patients who met the inclusion criteria are summarized in Table 1. The average age of all patients was 55.9 ± 11.7 years at the time of surgery, and 39 (29%) were male. The median Karnofsky Performance Status before surgery was 90 (IQR, 80–90), where 71 (52%) presented with headaches, 35 (26%) with vision deficits, 25 (18%) with seizures, 14 (10%) with anosmia, 11 (8%) with confusion/memory loss, 10 (7%) with motor
Discussion
In this study of 136 patients who underwent resection of an anterior SB meningioma, 20 (15%) underwent SB/retractorless, 12 (9%) SB/RA, 46 (34%) non-SB/retractorless, and 58 (43%) non-SB/RA surgery. Regarding SB approaches, patients who underwent SB compared with non-SB surgery had not only more frequent resolution of their FLAIR but also shorter median times to FLAIR resolution. Likewise, with retractorless surgery, patients who underwent retractorless compared with RA surgery had not only
Conclusions
As surgical techniques and technology progress, there is an increasing need to minimize collateral damage in neurosurgical procedures. One potential source is brain manipulation as a result of surgical approach and use of fixed retractor systems. For anterior SB meningiomas, we show that non-SB approaches and RA surgery are each associated with prolonged changes to the brain over time. The clinical significance of these changes is unclear. If possible, SB approaches and dynamic retraction
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.