Elsevier

World Neurosurgery

Volume 112, April 2018, Pages e505-e513
World Neurosurgery

Original Article
The Radiographic Effects of Surgical Approach and Use of Retractors on the Brain After Anterior Cranial Fossa Meningioma Resection

https://doi.org/10.1016/j.wneu.2018.01.069Get rights and content

Highlights

  • Use of skull base approaches results in less persistent radiographic changes to the brain

  • Avoidance of fixed retraction on the brain results in less persistent radiographic changes to the brain

  • Non-SB surgery and use of fixed retraction systems lead to the most persistent radiographic changes

  • The clinical implications of these radiographic changes remains poorly understood

Objective

There is an increasing trend toward skull base (SB) approaches and retractorless surgery to minimize brain manipulation during surgery. We evaluated the radiographic changes over time after surgical resection of anterior cranial fossa meningiomas with and without both SB approaches and/or fixed retractor systems.

Methods

All adults undergoing primary resection of an anterior cranial fossa World Health Organization grade I meningioma through a craniotomy at a single academic tertiary-care institution from 2010 to 2015 were retrospectively reviewed. Magnetic resonance imaging scans were reviewed and contrast-enhanced tumor and fluid-attenuated inversion recovery (FLAIR) volumes were measured. Matched-pair analyses between patients who underwent SB and non-SB approaches, as well as retractorless and retractor-assisted (RA) surgery, were made.

Results

Of the 136 total patients, 20 (15%), 12 (9%), 46 (34%), and 58 (43%) underwent SB/retractorless, SB/RA, non-SB/retractorless, and non-SB/RA surgery, respectively. Patients who underwent non-SB and RA surgery each independently had longer times to FLAIR resolution than those who underwent SB (20.9 vs. 5 months; P = 0.04) and retractorless (12 vs. 5.2 months; P = 0.02) surgery, respectively. Patients who underwent both non-SB and RA surgery had the longest median time to FLAIR resolution (30 months vs. 4 months in SB/retractorless, 3.6 months in SB/RA, and 3 months in non-SB/retractorless; P < 0.05).

Conclusions

The use of SB approaches in combination with retractorless surgery may decrease the duration needed for FLAIR resolution after surgery. The results from this study therefore advocate SB approaches and retractorless surgery along the anterior SB when possible.

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.

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