Neurosurg Rev (2011) 34:441455 DOI 10.

1007/s10143-011-0322-9

ORIGINAL ARTICLE

Endoscope-assisted microsurgical resection of skull base meningiomas

Henry W. S. Schroeder & Anne-Katrin Hickmann & Jrg Baldauf

Received: 16 November 2010 / Revised: 15 March 2011 / Accepted: 23 April 2011 / Published online: 26 May 2011 # Springer-Verlag 2011

Abstract This study aims to determine the value of endoscope assistance in the microsurgical resection of skull base meningiomas. Fourty-six patients harboring a skull base meningioma underwent an endoscope-assisted microsurgical resection. In 30 patients (65%), tumor parts which could not be visualized under the microscope were detected with the endoscope. In 26 patients (56%), these tumor remnants were removed under endoscopic view. Gross total resection was achieved in 35 patients (76%) and near-total resection in 11 (24%). There was no surgical mortality. The major complication was new cranial nerve deficit. The application of endoscopes was most useful in the small supraorbital craniotomies to look under the ipsilateral optic nerve and internal carotid artery as well as to visualize the diaphragm sellae and olfactory groove. In the retrosigmoid craniotomies, the endoscope was beneficial to inspect the internal auditory canal, to look into Meckels cave, or to inspect areas hidden behind the jugular tubercle and tentorial edge. There was no obvious complication related to the application of the endoscope. Endoscope assistance is particularly of value when skull base meningiomas are to be removed via small craniotomies to inspect blind corners which cannot be visualized in a straight line with the microscope. In addition, there is a benefit of using endoscopes with various angles of view in standard craniotomies and skull base approaches to look around bony and dural
H. W. S. Schroeder (*) : J. Baldauf Department of Neurosurgery, Ernst Moritz Arndt University, Sauerbruchstr, 17487 Greifswald, Germany e-mail: henry.schroeder@uni-greifswald.de A.-K. Hickmann Department of Neurosurgery, Katharinenhospital, Stuttgart, Germany

corners or to look behind neurovascular structures, by which the amount of skull base drilling and retraction to expose the tumor can be reduced. Keywords Endoscope-assisted microsurgery . Meningioma . Neuroendoscopy . Skull base

Introduction Skull base meningiomas are challenging lesions because of their close relationship to important neurovascular structures and the difficulty to approach them [8, 39, 42]. They may spread extensively along the skull base and often involve important vessels and nerves. Frequently, tumor parts are hidden behind bony corners of the cranial base and behind nerves and vessels. Therefore, visualization in a straight line with the microscope is sometimes difficult and requires extensive skull base drilling as well as retraction of brain and neurovascular structures. Therefore, theoretically, the use of endoscopes with various angles of view could be advantageous to improve visualization of these lesions. The aim of this study was to evaluate the benefit of endoscope assistance in the transcranial resection of skull base meningiomas.

Patients and methods Patients Fourty-six patients harboring a skull base meningioma underwent endoscope-assisted microsurgical resection at our institution between January 2002 and April 2009. The clinical characteristics of the patients are given in Table 1.

442

Table 1 Summary of clinical characteristics Tumor Tumor location size (cm) CPA TS CPA CPA OG OG PC MSW PC TS TS PC PC 3.11.53.8 4.43.53.6 rs (r) rs (r) GTR NTR Yes No Yes No 1.01.21.0 3.43.84.2 so (r) pt (r) GTR GTR Yes Yes Yes Yes Trochlear palsy Slight facial palsy (HB 2) 1.51.40.9 rs (r) GTR No No 2.81.03.0 pt (r) NTR No No 2.82.63.0 rs (l) GTR Yes Yes No No No No No No No 1.81.41.5 2.01.81.8 2.11.91.7 1.51.51.4 1.61.41.6 3.23.02.8 rs (r) pt (r) rs (r) rs (r) so (r) so (r) GTR GTR GTR GTR GTR GTR No Yes No Yes Yes Yes No Yes No Yes Yes Yes No No No No No No 101 65a 100 94 91 86 86 84 83 83 79 78 78 Surgical Extent of Tumor detected Tumor removed Complications approach resection endoscopically under endosc.view Neurological deficits Recurrence follow-up (months)

Patient no. Age (year), Symptoms sex

1 2 3 4 5 6

58, 50, 65, 46, 67, 50,

f m f m m m

Hypacusis, vertigo Hyposmia Hypacusis Headache Incidental finding Vertigo, headache

65, f

42, m

63, f

Hypacusis, tinnitus, balance problems Oculomotor palsy visual field deficit Incidental finding

Tinnitus Anosmia (sacrifice of olfactory tracts) Anacusis, dysphagia, facial palsy (HB 6), Visual loss, CSF fistula visual field deficit Abducens palsy

10 11

59, f 40, f

12 13

37, f 69, f

14 15 16 JF TS CPA PC OG MSW DS 3.42.82.9 3.95.24.0 fl (r) so (r) 2.01.81.6 rs (r) 3.22.63.5 pt (l) GTR GTR NTR GTR GTR pt (r) 3.82.84.1 1.92.01.6 rs (r) so (l) GTR NTR GTR 4.23.64.0 rs (l) NTR No No No Yes Yes Yes No No Yes

42, f 38, f 25, f

OG TJ PC

3.02.82.9 2.12.01.2 4.43.64.1

so (r) fl (l) rs (l)

GTR GTR NTR

Yes Yes No

Yes Yes No No No No No Yes No No No Yes

Hypacusis Trochlear palsy Lower cranial nerve palsy

No No No rad No No

77 75 74 73 70 70 67 Anosmia No No No No No 57a 28a 62 61 61

17

75, m

18

85, f

19

51, f

Headache Visual loss, visual field deficit Vertigo, facial numbness Headache, hypacusis, balance problems, vertigo hydrocephalus occlusus Headache, hyposmia Incidental finding Headache, vertigo, facial numbness Vertigo, hypacusis balance problems Visual loss, visual field deficit Hypacusis

20

46, f

Facial palsy (HB 6) No after 10 days Palsy VI (r,l), VII (HB 3)(r), No

21

78, m

22

77, m

4.45.1 3.8 pt (r) 1.51.81.6

23

53, f

Headache, hypacusis, hydrocephalus occlusus Frontal lobe syndrome, hyposmia Frontal lobe syndrome, gait disturbance Visual field deficit

24

77, f

CSF fistula (revision) decreased visual acuity

Neurosurg Rev (2011) 34:441455

25

61, f

Gait disturbances, PC hydrocephalus occlusus Headache PS

Table 1 (continued) Tumor Tumor location size (cm) PB CPA CPA TS OG MSW 4.63.2 4.4 pt (l) GTR No No Oculomotor palsy, 3.84.4 3.6 so (r) GTR Yes Yes No No 2.92.82.6 so (r) GTR Yes Yes No 56 55 52 4.03.84.0 1.41.31.5 1.51.41.4 rs (l) rs (r) rs (l) GTR GTR GTR No Yes Yes No Yes Yes CSF fistula (lumbar drain) CSF fistula (lumbar drain) Diplopia, vertigo No No No 58 57 57 Surgical Extent of Tumor detected Tumor removed Complications approach resection endoscopically under endosc.view Neurological deficits Recurrence follow-up (months)

Patient no. Age (year), Symptoms sex

26 27 28

65, m 66, f 51, f

29

61, f

30

66, f

Neurosurg Rev (2011) 34:441455

31

70, f

32 33 PC TS PS TS IM PC 1.30.60.6 4.53.54.4 rs (r) emf (l) GTR NTR No Yes No Yes 2.01.71.8 2.52.52.4 so (r) so (r) GTR GTR Yes Yes Yes Yes 3.12.72.8 1.82.02.1 rs (l) pt (r) NTR GTR Yes No Yes No

35, f 78, f

PB MSW

2.93.33.1 4.04.14.4

rs (r) pt (l)

GTR GTR

Yes No

Yes No

No No No No No No No No

51 50 50 43 40 39 36 33

34 35

69, m 72, m

36 37

67, f 55, f

Abducens palsy Cerebral infarction chronic subdural hematoma

38 39

54, f 36, f

40 41 PB MSW PC PC PC 3.02.82.3 rs (l) 2.31.82.1 rs (l) NTR NTR Yes No 4.23.72.8 1.31.41.2 4.64.44.1 rs (l) so (r) rs (l) GTR GTR NTR Yes yes Yes

50, f 31, f

CPA PC

1.91.81.7 2.32.12.6

rs (r) rs (l)

GTR GTR

Yes Yes

Yes No Yes yes No Yes No

Total ophthaloplegia, trochlear nerve sacrifice hemiparesis Meningitis

No No No no No No Anacusis No

31 26 23 19 18 15 14

42 43 44

53, f 47, f 49, f

Incidental finding Incidental finding Headache, hypacusis, tinnitus Visual loss, visual field deficit Headache, visual loss, visual field deficit Headache, facial numbness, aphasia, vertigo, visual loss Tinnitus Incidental finding after minor stroke Hypacusis, vertigo Visual loss, visual field deficit Incidental finding Visual loss, visual field deficit Facial palsy, anacusis Partial ophthalmoplegia visual field deficit, facial numbness Hypacusis, vertigo Hypacusis, vertigo, facial numbness Hypacusis, vertigo Headache Headache, vertigo Oculomotor, abducens (r+l), facial palsy (HB 2)

45

60, m

Headache

46

57, f

Headache, vertigo

TS tuberculum sellae, PS planum sphenoidale, PC petroclival, CPA cerebellopontine angle, IM intrameatal, OG olfactory groove, TJ tuberculum jugulare, JF jugular foramen, MSW medial sphenoid wing, pt pterional, so supraorbital, fl far lateral, rs retrosigmoid, emf extended middle fossa, (l) left side, (r) right side, size axialsagittalcoronal in centimeter

Died

443

444

Neurosurg Rev (2011) 34:441455

Data were collected from a prospectively maintained database and a retrospective review of medical records, operative reports, and magnetic resonance (MR) images. The study was approved by the Institutional Review Board of the University of Greifswald. The series consisted of 34 females and 12 males. The mean age of the patients at the time of surgery was 57 years, ranging from 25 to 85 years. The patients presented with headache (33%), cranial nerve deficits (63%), gait disturbances (4%), balance problems (6%), and/or mental changes (4%). In seven patients, the tumor was an incidental finding. Three months after discharge and then on a yearly basis, neurological evaluation was performed at the time of follow-up visits. Neuroradiological evaluation All patients underwent contrast-enhanced MR imaging before surgery. The tumor location was petroclival (13), cerebellopontine angle (7), tuberculum sellae (7), olfactory groove (5), medial sphenoid wing (5), petrous bone (3), planum sphenoidale (2), intrameatal (1), jugular tubercle (1), jugular foramen (1), and dorsum sellae (1). A cerebellopontine angle meningioma was defined as a meningioma arising from the petrous bone close to the internal auditory canal. The size of the tumors is given in Table 1 showing the largest axial, sagittal, and coronal diameter. The tumor size ranged from 1.30.60.6 to 4.6 4.44.1 cm. The day after surgery, a computed tomography (CT) scan was obtained to rule out intracranial complications. Three months after discharge and then on a yearly basis contrast-enhanced MR imaging was performed at the time of follow-up visits in all patients except one (patient 24) who received a cardiac pacemaker after surgery. In this patient, contrast-enhanced CT scans were performed. Surgical technique All surgical interventions were performed by the senior author (HWSS). Cranial nerve monitoring was used in all

posterior fossa lesions. There were 23 retrosigmoid, 11 supraorbital, 9 pterional, 2 far lateral, and 1 extended middle fossa approach with anterior petrosectomy. Most of the surgery was done under microscopic view. When deemed helpful, endoscopes were applied to aid in visualization of the surgical field. Rigid rod-lens endoscopes (outer diameter 4 or 2.7 mm, Karl Storz GmbH & Co. KG, Tuttlingen, Germany) with angulated eye piece especially designed for endoscope-assisted microsurgery were utilized. Four different angles of view (0, 30, 45, and 70) were available. In all patients, the endoscope was used freehand for inspection during the surgery and after completing the tumor removal (Fig. 1a). If tumor remnants were detected which could not be seen under the microscope, the endoscope was fixed to an endoscope-holding arm, and tumor parts were resected bimanually under endoscopic vision (Fig. 1b and c). The histological investigation revealed a meningioma World Health Organization grade 1 in all patients. Evaluation of extent of tumor resection Gross total resection (GTR) was defined as no intraoperative evidence of residual tumor and no evidence of contrast-enhancing tumor on postoperative imaging. Neartotal resection (NTR) was defined as intraoperatively observed residual tumor despite negative postoperative MR, extracavernous contrast-enhancing tumor tissue less than 5 mm and intracavernous/Meckels cave residual tumor less than 1 cm. Benefit of endoscopic visualization The benefit of endoscopic application was prospectively recorded. The usefulness of the endoscope was assessed regarding the detection of tumor tissue which was not visible under the microscope as well as the ability to remove tumor tissue under endoscopic visualization. Technical problems were additionally noted throughout the study period.

Fig. 1 Endoscopic set-up. a Freehand application of the endoscope for inspection. b and c Fixation of a 30 endoscope with an endoscopeholding arm and bimanual resection of a tumor remnant in the olfactory groove

Neurosurg Rev (2011) 34:441455

445

Results Extent of tumor resection The extent of tumor removal is described in detail in relation to tumor location in Table 2. GTR was achieved in 35 patients (76%), NTR in 11 (24%). As expected, most of the NTR were intentionally performed in the petroclival meningiomas to avoid permanent neurological deficits. The reason for leaving small residual tumor tissue behind was infiltration of the cavernous sinus/Meckels cave in four (patients 13, 16, 39, and 46), pial invasion of the brainstem in three patients (patients 24, 34, and 45), adherence to the basilar artery in one (patient 44), and infiltration of the right hypoglossal nerve/canal in one (patient 20). In patient 17, who presented with a large tumor originating at the jugular foramen, NTR was performed to avoid permanent damage to the infiltrated lower cranial nerve group. In patient 8 harboring multitopic meningiomatosis, NTR of the tumor nodule at the tuberculum sellae and medial sphenoid wing was done to decompress the right optic nerve and chiasm. In all patients with extracavernous tumor residuals, only very small remnants of the tumor capsule (about 25 mm thin layers) were left in place. Recurrence The mean follow-up period was 58.8 months, ranging from 14 to 101 months. One young patient (patient 16) underwent hypofractionated stereotactic radiation of a tumor remnant within the cavernous sinus/Meckels cave because of slight tumor progression observed 12 months after surgery. So far, the tumor remnants in the other 10 patients with NTR are stable without any treatment (mean follow-up, 49 months). To date, no recurrences have been observed in the patients who underwent GTR.

Complications and neurological outcome All complications are listed in Table 1. There was no surgical mortality. Three patients (patients 2, 21, 22) died of unrelated causes 65, 57, and 28 months after surgery. Details of the surgery-related new neurological deficits are given in Table 3. The major complication was new cranial nerve deficit in 20 patients (43%), which was transient in 13 patients. In seven patients (15%), a permanent cranial nerve deficit remained. In patient 6, both olfactory tracts were intentionally sacrificed to achieve GTR because of infiltration of the lamina cribrosa. Patient 35 experienced a hemiparesis after an intraoperative stroke related to a severe middle cerebral artery stenosis which had been asymptomatic and unrecognized prior to surgery. The same patient underwent evacuation of a chronic subdural hematoma 4 months after surgery. Patient 28 complained of persistent dizziness although no objective signs of vestibular dysfunction were found. In four patients (patients 8, 23, 26, and 27), a cerebrospinal fluid (CSF) fistula developed leading to rhinoliquorrhoe in three and subgaleal CSF accumulation in one of them (patient 8). The cause of the fistula in patients 26 and 27 was a paper-thin dura and widely opened mastoid air cells. In three patients, the fistula resolved after 45 days of lumbar drainage. Patient 23 required a surgical revision with closure of the fistula. Patient 41 experienced meningitis which resolved quickly after antibiotic medication without sequelae. While two patients (patients 7 and 46) lost their hearing completely after surgery despite anatomical preservation of the vestibulocochlear nerves, in four patients hearing improved markedly (patients 17, 19, 20, and 34). Of the seven patients with tuberculum sellae meningiomas, five presented with decrease in visual acuity and visual field deficits. In all patients, an improvement of visual acuity and visual field cuts was observed after surgery. In none of these patients did a surgery-related deterioration of vision occur. In the patient presenting with a dorsum sellae meningioma (patient 23), the preexisting visual field deficit was slightly exacerbated and the visual acuity on one eye decreased temporarily. In the patient presenting with meningiomatosis and optic canal invasion (patient 8), a temporary visual loss was noted. Benefit of the endoscope Details of the benefit of endoscope-assistance are given in Table 4 in relation to the various approaches. The application of an endoscope was most useful in the small supraorbital craniotomies. In all supraorbital approaches, we found residual tumor which could not be visualized with the operating microscope (Fig. 2). In all cases, these tumor remnants were removed under endoscopic vision. The

Table 2 Relation of tumor location and extent of resection Tumor location Petroclival Cerebellopontine angle Tuberculum sellae Olfactory groove Medial sphenoid wing Petrous bone Planum sphenoidale Intrameatal Jugular tubercle Jugular foramen Dorsum sellae n 13 7 7 5 5 3 2 1 1 1 1 GTR (%) 4 (31) 7 (100) 7 (100) 5 (100) 4 (80) 3 (100) 2 (100) 1 (100) 1 (100) 1 (100) NTR (%) 9 (69) 1 (20) 1 (100)

446 Table 3 New neurological deficits Patient no. Neurological deficits prior to surgery 4 6 7 Vertigo Hypacusis, tinnitus, balance problems Tumor location New neurological deficit CPA OG PC Tinnitus Anosmia (sacrifice of olfactory tracts) Anacusis Facial palsy (HB 6) Dysphagia Visual loss Abducens palsy Trochlear palsy Facial palsy (HB 2) Hypacusis Trochlear palsy Lower cranial nerve palsy

Neurosurg Rev (2011) 34:441455

Transient Permanent Improved to HB 3

8 9 12 13 15 16 17 19 20

Oculomotor palsy visual field deficit MSW PC Vertigo facial numbness PC Headache, hypacusis, balance problems, vertigo PC hydrocephalus occlusus TJ Vertigo facial numbness PC Vertigo, hypacusis balance problems JF Hypacusis Hypacusis, hydrocephalus CPA PC

21 23 28 31

Frontal lobe syndrome hyposmia Visual field deficit Hypacusis, tinnitus Facial numbness Aphasia, vertigo Visual loss Hypacusis, vertigo Visual loss Partial ophthalmoplegia Visual field deficit Facial numbness Vertigo

OG DS CPA MSW

Facial palsy (HB 6) 10 days after surgery Bilateral abducens palsy Right facial palsy Right lower cranial nerve palsy Bilateral hypoglossal palsy Anosmia Decreased visual acuity Visual field deficit increased Diplopia Vertigo Oculomotor Palsy

34 35 39

PC TS PC

44

PC

Abducens palsy Hemiparesis due to cerebral infarction Oculomotor palsy Trochlear palsy (nerve sacrifice) Abducens palsy Hemiparesis Oculomotor palsy Bilateral abducens palsy Facial palsy (HB 2) Anacusis

46

Vertigo

PC

TS tuberculum sellae, PC petroclival, CPA cerebellopontine angle, OG olfactory groove, TJ tuberculum jugulare, JF jugular foramen, MSW medial sphenoid wing

endoscope was used to look under the ipsilateral optic nerve and internal carotid artery as well as to visualize the diaphragm sellae and olfactory groove. In the retrosigmoid craniotomies, we found tumor tissue not visible with the microscope in 13 patients and removed tumor under endoscopic control in 11 of them. The endoscope was beneficial in inspecting the internal auditory canal (Fig. 3), in looking into Meckels cave or in inspecting areas hidden

behind the jugular tubercle and tentorial edges such as the supratentorial compartment (Fig. 4). Additionally, it was useful to look to the contralateral side of the skull base or brainstem after resection of larger tumors. In the extended middle fossa approach, the endoscope was extremely useful to look under the edge of the petrous bone to visualize the tumor part close to cranial nerves VII and VIII in the cerebellopontine angle (Fig. 5). In the far lateral

Neurosurg Rev (2011) 34:441455 Table 4 Benefit of endoscopeassistance in the various surgical approaches Approach Supraorbital Retrosigmoid Pterional Far lateral Ext. middle fossa n 11 23 9 2 1 Endoscopic tumor detection (%) 11 13 3 2 1 (100) (56) (33) (100) (100)

447 Endoscopic tumor removal (%) 11 11 2 1 1 (100) (48) (22) (50) (100)

approaches, the endoscope was applied to look behind the jugular tubercle and vertebral artery and to inspect the hypoglossal canal. The endoscope was of less value in the pterional approaches. Only in three patients was residual tumor found with the endoscope under the ispilateral optic nerve and carotid artery. In two of them, tumor was removed under endoscopic view although a safe resection under microscopic vision would have been possible too. There was no obvious complication related to the application of the endoscope, although it is impossible to rule out completely that some additional trauma to the neurovascular structures occurred while using the endoscope, for example because of the heat at the tip of the endoscope.

Discussion Since Perneczky pioneered the concept of endoscopeassisted microsurgery [16, 31], several reports have suggested a beneficial effect of using endoscopes while performing intracranial microsurgical procedures [2, 6, 7, 18, 21, 23, 27, 33, 38, 41]. However, the value of endoscope assistance in the resection of skull base meningiomas has not yet been specifically addressed prior to this report. Rationale of endoscope-assisted microsurgery The operating microscope provides an excellent stereoscopic view. However, in deep and narrow surgical corridors, there is a considerable loss of light at the entry point. Furthermore, the surgeon works within the light beam, which further decreases the light intensity in the surgical field. With the microscope, only structures which are visible in a straight line can be explored. Compared with the operating microscope, the endoscope provides a completely different view. State-ofthe-art endoscopes containing a Hopkins II rod lens have a wide-angle viewing field resulting in a panoramic view. Therefore, even lesions which are not located directly in front of the endoscope tip can be recognized early. This is a major advantage in narrow and deep surgical approaches. Using endoscopes with various angles of view, gives the ability to look around a corner or behind neurovascular

structures, which is very useful in skull base surgery. With the use of an endoscope, the surgeon brings the eye close to the target area with perfect illumination even in the depth. Another important advantage of the endoscope compared with the microscope is the excellent depth of field. Refocusing, which is frequently required with the microscope, particularly with high magnification, is here rarely necessary. Of course, the endoscope also has limitations. The major drawback of the endoscope is the lack of true 3D viewing. However, because of the fish eye effect, the endoscopic image is distorted and provides a pseudo-3D impression. Furthermore, motion parallax, which means closer objects move more than distal objects, contributes to the pseudo3D impression of an endoscopic image. Therefore, the lack of stereopsis is usually compensated for with some training. Another disadvantage of the endoscope is the lower resolution compared to the microscope. Because of the smaller lens diameter of the endoscopes used in neuroendoscopy, the operating microscope has still the better resolution. Furthermore, when using the operating microscope, the surgeon has a very good resolution because he is looking directly through the lens system. The sensor is the retina, which is much better then CCD chips in the minivideo cameras which are attached to the endoscope. Although recently introduced high-definition cameras generate images with 1,080 lines and over 2 million pixels [37], the image quality is still inferior to direct perception by the human eye through the microscope. In conclusion, both the microscope and the endoscope have their advantages and disadvantages. Therefore, it sounds reasonable to combine the advantages of both optical instruments during neurosurgery. Is endoscopy truly useful in the resection of skull base meningiomas? Microsurgical resection has been the treatment of choice for skull base meningiomas for many years. Excellent results have been achieved [4, 13, 24, 26, 30, 40]. The logical question thus arising is: is endoscopy truly necessary? Is it helpful? Or only a gimmick to take nice close-ups? In our opinion, endoscope assistance is very useful in selected cases; but in some others, it is not. This series represents a

448

Neurosurg Rev (2011) 34:441455

Fig. 2 Pre- and postoperative MR imaging and intraoperative images of patient 37 presenting with visual field deficit and visual loss. ac T1-weighted contrast-enhanced axial (a), sagittal (b), and coronal (c) MR images showing a tuberculum sellae meningioma. d Microscopic visualization of the suprasellar region via a supraorbital craniotomy showing left (LO) and right (RO) optic nerve. The sellar diaphragm cannot be visualized because of the orbital roof (OR). e Endoscopic inspection with a 30 endoscope revealed the left internal carotid artery (c), left (LO) and right (RO) optic nerves, the pituitary stalk (PS), and a tumor remnant (T) which could not be visualized with the

microscope. f Bimanual tumor resection under endoscopic view. g Tumor resection medial to the right optic nerve (RO). h Endoscopic view after gross total tumor resection showing left (LO) and right (RO) optic nerve and the pituitary stalk (PS). i Fixation of the bone flap with two mini-plates. j Photograph taken 4 months after surgery showing an excellent cosmetic result. k Postoperative CT scan showing the size of the craniotomy (arrows). lk T1-weighted contrast-enhanced axial (a), sagittal (b), and coronal (c) MR images obtained 39 months after surgery showing no tumor remnant or recurrence

highly selected group of patients. In the study period, 97 additional skull base meningiomas were microsurgically resected without additional use of an endoscope because we felt it was not of value. That means that only about one third of the patients presenting with skull base meningio-

mas were treated with endoscope assistance. The endoscope was not used in large meningiomas of the frontal skull base, which were approached via a frontolateral craniotomy of about 44 cm in size. Because of the height of the craniotomy enabling a steep angle of view and the space

Neurosurg Rev (2011) 34:441455

449

Figure 3 Pre- and postoperative MR imaging and intraoperative images of patient 4 presenting with headache. a T1-weighted contrastenhanced axial MR image showing a cerebellopontine angle (CPA) meningioma with tumor extension growing into the internal auditory canal (IAC) (arrow). b Microscopic appearance of the tumor within the CPA. c IAC after drilling of the posterior wall and microsurgical

tumor removal. No tumor remnant was seen in the fundus (arrows). d With a 30 endoscope, a small tumor remnant (arrows) which was not detected by the microscope can clearly be seen. e Removal of the tumor under endoscopic view. f T1-weighted contrast-enhanced axial MR image obtained 94 months after surgery showing the total tumor removal and no recurrence within the IAC (arrow)

provided by the tumor resection, the entire frontal skull base can be visualized with the operating microscope. The same is true for pterional or interhemispheric approaches. We agree that endoscopy is usually not necessary in these operations. However, when tumors of the frontal skull base are approached via a small supraorbital craniotomy, the endoscope is very useful and sometimes mandatory in order to obtain a GTR. Tumor parts within the olfactory groove, for example, cannot be visualized with the microscope, because of the flat angle of view and the orbital roof which obscures the view. With a 30 endoscope, however, a good overview of the olfactory groove can be obtained and the tumor removed with angulated curettes and bipolar forceps (Fig. 1c). Additionally, the endoscope is used to look under the ipsilateral optic nerve and internal carotid artery as well as to visualize the diaphragm sellae. Because of the small craniotomy diameter, only narrow viewing angles can be obtained providing a coaxial view to the surgical instruments which can be overcome with angulated optics. Another problem of the keyhole approaches is the poor illumination in the depth of the field when using the microscope, which can be solved with endoscopy [34]. In all of our supraorbital approaches, tumor parts were both detected and removed under endoscopic view, although Fatemi et al. [14] used endoscopes only in three of seven tuberculum sellae meningiomas which were removed via a supraorbital approach. This difference might be explained by variations in the height of the craniotomy, the steepness of the skull base, and the surgeons enthusiasm for endoscopy.

Additionally, we found the application of endoscopy very helpful in meningiomas extending deeply into the internal auditory canal. When hearing preservation is demanded, the extent of drilling of the posterior wall of the internal auditory canal should be limited by the vestibule and the posterior semicircular canal. The angle of viewing does not allow direct inspection of the fundus of the internal auditory canal with the aid of the microscope even after extensive drilling of the posterior wall of the internal auditory canal. A blind dissection of the distal tumor pole can be performed with the aid of a hook dissector or curved curettes. However, using a 30, 45, and 70 endoscope enables a perfect visualization of the fundus. Tumor remnants can be detected and removed under endoscopic vision (Fig. 3) or the endoscope is simply used freehand for inspection after tumor removal to make sure that the tumor has been totally removed. After tumor removal, the drilled area of the internal auditory canal is inspected to find open air cells which might cause CSF leak. Furthermore, the endoscope-assisted technique may be a useful adjunct to extensive microsurgical skull base surgeries. Endoscopes can be used in removing tumor parts hidden behind the jugular and suprameatal tubercle as well as in looking into Meckels cave [12]. We demonstrate the application of a 30 endoscope in the extended middle fossa approach [9] to facilitate the look into the infratentorial compartment. Although the endoscope was only used for about 10 min in this time-consuming, mainly microsurgical procedure, it was truly beneficial for identification and

450

Neurosurg Rev (2011) 34:441455

Fig. 4 Pre- and postoperative MR imaging and intraoperative images of patient 44 presenting with headache and vertigo. ae T1-weighted contrast-enhanced axial MR images showing a large petroclival meningioma. f Microscopic exposure of the lower cranial nerves (arrow) in front of the tumor (T). g Microscopic transsection of the tentorium to achieve access to the supratentorial tumor part. h Final microscopic image after near-total tumor resection. i Endoscopic

inspection of the internal auditory canal in front of the vestibulocochlear nerve (VC). j Endoscopic image of the contralateral oculomotor nerve (OC) running over the P1 segment of the posterior cerebral artery (P1). k Endoscopic visualization of the ipsilateral oculomotor (OC) and optic nerve (ON). lp T1-weighted contrastenhanced axial MR images obtained 18 months after surgery showing no tumor remnant or recurrence

removal of tumor in front of the vestibulocochlear and facial nerves hidden behind the petrous bone (Fig. 5). The amount of drilling required for optimal exposure could be reduced as well as the risk of damaging the cochlea resulting in deafness. For petroclival meningiomas, transpetrosal approaches have been recommended [8, 25, 40]. However, even with extensive transpetrosal approaches, the central clival depression may not be exposed adequately and tumor may be left behind [1]. Resection of the jugular tubercle via a far lateral

transcondylar approach may be an option to expose that area [22]. But, with angled endoscopes, the central clival depression can easily be visualized without additional drilling via a simple retrosigmoid craniotomy and a total tumor resection can be achieved. We agree with Samii et al. [35, 36] and Bambakidis et al. [3] that even large petroclival meningiomas can be resected safely via a simple retrosigmoid craniotomy avoiding the complications of a transpetrosal approach. All except one petroclival tumor in our series were removed via the retrosigmoid route. Similarly, in

Neurosurg Rev (2011) 34:441455 Fig. 5 Pre- and postoperative MR imaging and intraoperative images of patient 39 presenting with partial ophthalmoplegia, visual field deficit, and facial numbness. ad T1-weighted contrast-enhanced axial MR images showing a large petroclival meningioma with perifocal edema in the cerebral peduncle (arrows). ef T1-weighted contrastenhanced coronal MR images showing the significant supratentorial extension. f Microscopic exposure via an extended middle fossa approach with anterior petrosectomy showing the abducens nerve in the depth (arrow) behind the petrous bone (PB). i Microscopic infratentorial tumor resection behind the petrous bone (PB). Vestibulocochlear and facial nerves are not visible. j Endoscopic view with a 30 endoscope showing a tumor remnant (T) in front of the vestibulocochlear (VC) and facial (f) nerve. k Endoscopic removal of the tumor (T) with an angulated curette. l CT scan obtained 1 day after surgery showing the extent of the petrous apex resection (arrows). mo T2-weighted axial MR images obtained 3 months after surgery showing a small infarction at the lateral aspect of the midbrain (arrow), but no retraction injury to the temporal lobe. The moderate hemiparesis observed after surgery disappeared completely within 3 weeks. ps T1-weighted contrast-enhanced axial MR images obtained 33 months after surgery showing no tumor remnant or recurrence. tv T1-weighted contrastenhanced coronal MR images obtained 33 months after surgery showing the residual tumor infiltration in the cavernous sinus (arrow)

451

452

Neurosurg Rev (2011) 34:441455

the far lateral approaches, the endoscope was used to look behind the jugular tubercle and remove tumor around the entry into the hypoglossal canal. Drilling of the jugular tubercle as well as resection of the condyle could be avoided. The endoscope-assisted technique was rarely helpful in the pterional approaches. The pterional approaches give similar like the frontolateral approaches enough space to inspect the entire frontal skull base with the microscope. However, angled endoscopes can be applied to visualize the space hidden behind the ipsilateral carotid artery or to look under the optic nerve without any retraction. Endoscopes were only applied if GTR or NTR was the goal of the surgery. It makes no sense to use the endoscope additionally to the microscope if only a subtotal resection for decompression of the brainstem is intended, such as in old patients with petroclival meningiomas which do not respect the pial border of the brainstem. In summary, using the endoscope in conjunction with the operating microscope may provide additional exposure and better access in skull base surgery [5]. Technical considerations In endoscope-assisted microsurgery, usually the major part of the procedure is performed under microscopic view because of the better image quality and the 3D view provided by the operating microscope. Only some steps of the surgery are carried out under endoscopic view. The endoscope is mostly used to look around bony or dural corners as well as neurovascular structures to decrease the amount of skull base drilling and retraction to expose a lesion. Furthermore, the endoscope is applied in deep and narrow surgical corridors to improve illumination and viewing field. Endoscopic inspection and dissection was mostly done with the aid of a 30 or 45 scope. Seventydegree endoscopes were sometimes used for inspection, but rarely for dissection since the manipulations are more demanding because of the sharp angle of view. To avoid fogging of the lens after inserting the endoscope, we put the scopes into warm sterile saline at 37C before use. The lens is cleaned by irrigation or wiping. Although having the endoscope held by an assistant is standard in endonasal skull base surgery [10] and has additionally been reported in transcranial removal of an epidermoid from the cerebellopontine angle (CPA) [11], we prefer fixing the endoscope to an endoscope-holding arm while bimanual dissection is performed. Our impression is that this technique is safer regarding potential damage to neurovascular structures. Especially in the CPA when the endoscope has already passed nerves VII and VIII to visualize tumor in the depth, unintentional lateral movements of the scope may cause cranial nerve deficits. Therefore, care has to be taken when moving the endoscope

and inserting the instruments or removing them from the surgical field to avoid damage to neurovascular structures which are behind the tip of the endoscope and not under endoscopic view. And last but not least, it is of utmost importance to keep in mind that the tip of the endoscopes may become really hot, which may damage neurovascular structures, especially during prolonged dissections under endoscopic view. Therefore, frequent irrigation is recommended. Transcranial versus endonasal approaches Recently, promising results have been published regarding endoscopic endonasal resection of skull base meningiomas [10, 14, 15, 17, 19]. One attraction is the rapid access to the vascular supply of the tumor and the avoidance of any brain retraction to expose the lesion. However, although the endonasal approach is considered to be a minimally invasive approach to the skull base, significant trauma to the nasal cavity and paranasal sinuses is caused when approaching the cranial base via the nose. Often, at least one middle turbinate is resected, the sphenoid sinus is opened widely, the ethmoidal cells are removed, and depending from the location and size of the meningioma the cranial base has to be resected to a certain extent. Swelling of the paranasal mucosa and crusting are often seen even 4 or more weeks after surgery. Closure of the cranial base defect created is another problem resulting in a relatively high rate of CSF leak, although the nasoseptal flap has improved the leakage rate [20]. Our experience with the endonasal approach for skull base meningiomas is very limited (four cases); however, it is our impression that the postoperative discomfort for the patient is greater and more prolonged after the endonasal approach than with eyebrow craniotomy. Furthermore, sometimes, the lateral tumor margins extend markedly wider than expected from preoperative MR imaging. The transcranial approach provides a good overview over the frontal skull base. With the endonasal approach, the view behind the lateral edges of the opened skull base is very limited and evens more the possibilities of removing tumor from these areas. Risking loss of olfaction is another disadvantage of the endonasal route. Removing olfactory groove meningiomas from the nose mostly results in anosmia. With the transcranial approach olfaction may be preserved even after GTR if the tumor has not invaded the area where the rootlets cross the dura and go to the nasal mucosa. In our series, we were able to preserve olfaction in three of five patients with olfactory groove meningiomas and in two patients with planum sphenoidale meningiomas which extented into the olfactory goove. In one patient, the olfactory tracts were intentionally sacrificed to achieve GTR because of lamina cribrosa infiltration. We lost olfaction unintentionally only

Neurosurg Rev (2011) 34:441455

453

in one patient who presented with significant hyposmia before surgery. Anosmia is usually not considered to be a severe deficit. However, if the patient is a red wine lover, as are the authors, loss of olfaction would be a tremendous decrease in quality of life and should therefore be avoided whenever possible. After having stated this criticism, we agree that the endonasal approach is the preferred route of access in patients with a subchiasmatic lesion and a prefixed chiasm because any transcranial approach will require retraction to the optic apparatus with the risk of visual decline. Small midline tuberculum sellae meningiomas (<2 cm) are, of course, another good indication for an endonasal approach. However, in general we prefer the supraorbital craniotomy via eyebrow incision for small frontal skull base meningiomas and the frontolateral approach for larger tumors. Neurological and radiological outcome The aim of our study was not to compare the results with microsurgical series. A comparison of the neurological and radiological outcome of our series with other studies makes no sense, because our cohort of patients is very heterogeneous and highly selected. Gross total microsurgical removal of skull base meningiomas is considered the therapy of choice [24, 28, 29]. However, recently, there is a trend towards less aggressive approaches to improve the quality of life of the patients. Tumor parts within the cavernous sinus should be left in place to avoid neurological deficits [4, 32]. It has been reported that in petroclival meningiomas, NTR achieved better functional results than GTR with the same recurrence rate [24]. This is in accordance with our experience. We did not undertake an attempt to remove tumor remnants from the cavernous sinus and we left tumor infiltrating the brainstem or adherent to the basilar artery behind. Only in one young patient did we observe tumor progression, and radiation was initiated. The ten other tumor remnants were stable within a mean follow-up period of 49 months. To date, no recurrence has been noticed in the patients having undergone GTR. GTR was always our preferred goal of surgery, however, not at the cost of new permanent neurological deficits. Transient deficits were accepted if the chance of GTR existed since significant neurological improvement after resection of petroclival meningiomas can be expected [40]. Major determining factors for GTR were a preserved arachnoid plane and the degree of adherence of the tumor to neurovascular structures. Tumor parts infiltrating nerves or vessels were left in place to avoid neurological deficits. The major complication was new cranial nerve deficit in 20 patients (43%). Most of these occurred as expected in the petroclival meningiomas. Fortunately, most deficits were

transient. Only in seven patients (15%) did a permanent cranial nerve deficit remain. An increase of a preexisting visual field deficit and a transient loss of visual acuity occurred in the patient with a dorsum sellae meningioma which was difficult to expose and required some retraction of the right optic nerve. In this patient, an endonasal approach might have been a better option. However, all five patients with tuberculum sellae meningiomas presenting with visual loss and visual field deficits improved to a certain extent. Serviceable hearing was lost in two patients. However, on the other hand hearing improved in four, which is well-known after resection of meningiomas in the CPA [26].

Conclusion Endoscope-assisted microsurgery for the resection of skull base meningiomas is a promising technique combining the advantages of the operating microscope with those of the endoscope. For resection of tumor parts which are visible in a straight line, the microscope with high resolution, excellent color fidelity as well as stereoscopic vision is the optimal visualization tool. For working around a corner, the endoscope is applied to reduce the amount of retraction and skull base drilling. This endoscope-assisted microsurgical technique enables a safe removal of skull base meningiomas even when tumor parts are not visible in a straight line. It still remains open whether endoscope assistance will improve the results; however, it definitely reduces surgical trauma. Using endoscopes during microsurgical procedures allows a reduction of the craniotomy size, improves illumination and visualization, and enables the surgeon to look around bony corners and important neurovascular structures, thus eliminating or at least reducing the need for skull base drilling as well as brain retraction.
Acknowledgment We thank Marc Matthes, M. Sc., for his help in preparing the illustrations. Disclosure HWSS is consultant to Karl Storz GmbH & Co. KG (Tuttlingen, Germany).

References
1. Abdel Aziz KM, Sanan A, van Loveren HR, Tew JM Jr, Keller JT, Pensak ML (2000) Petroclival meningiomas: predictive parameters for transpetrosal approaches. Neurosurgery 47:139150 2. Baldauf J, Junghans D, Schroeder HW (2005) Endoscope-assisted microsurgical resection of an intraneural ganglion cyst of the hypoglossal nerve. J Neurosurg 103:920922 3. Bambakidis NC, Kakarla UK, Kim LJ, Nakaji P, Porter RW, Daspit CP, Spetzler RF (2008) Evolution of surgical approaches in

454 the treatment of petroclival meningiomas: a retrospective review. Neurosurgery 62:11821191 Bassiouni H, Asgari S, Sandalcioglu IE, Seifert V, Stolke D, Marquardt G (2009) Anterior clinoidal meningiomas: functional outcome after microsurgical resection in a consecutive series of 106 patients. Clinical article. J Neurosurg 111:10781090 Batay F, Vural E, Karasu A, Al-Mefty O (2002) Comparison of the exposure obtained by endoscope and microscope in the extended trans-sphenoidal approach. Skull Base 12:119124 Beems T, Grotenhuis JA, Wesseling P (1999) Meningioma of the pituitary stalk without dural attachment: case report and review of the literature. Neurosurgery 45:14741477 Cohen AR, Perneczky A, Rodziewicz GS, Gingold SI (1995) Endoscope-assisted craniotomy: approach to the rostral brain stem. Neurosurgery 36:11281130 Couldwell WT, Fukushima T, Giannotta SL, Weiss MH (1996) Petroclival meningiomas: surgical experience in 109 cases. J Neurosurg 84:2028 Day JD, Fukushima T, Giannotta SL (1994) Microanatomical study of the extradural middle fossa approach to the petrocival and posterior cavernous sinus region: description of the rhomboid construct. Neurosurgery 34:10091016 de Divitiis E, Cavallo LM, Cappabianca P, Esposito F (2007) Extended endoscopic endonasal transsphenoidal approach for the removal of suprasellar tumors: part 2. Neurosurgery 60:4658 de DO, Cavallo LM, Dal FM, Elefante A, Cappabianca P (2007) Freehand dynamic endoscopic resection of an epidermoid tumor of the cerebellopontine angle: technical case report. Neurosurgery 61:E239E240 Ebner FH, Koerbel A, Kirschniak A, Roser F, Kaminsky J, Tatagiba M (2007) Endoscope-assisted retrosigmoid intradural suprameatal approach to the middle fossa: anatomical and surgical considerations. Eur J Surg Oncol 33:109113 Erkmen K, Pravdenkova S, Al-Mefty O (2005) Surgical management of petroclival meningiomas: factors determining the choice of approach. Neurosurg Focus 19:E7 Fatemi N, Dusick JR, de Paiva Neto MA, Malkasian D, Kelly DF (2009) Endonasal versus supraorbital keyhole removal of craniopharyngiomas and tuberculum sellae meningiomas. Neurosurgery 64:269284 Fernandez-Miranda JC, Gardner PA, Prevedello DM, Kassam AB (2009) Expanded endonasal approach for olfactory groove meningioma. Acta Neurochir (Wien) 151:287288 Fries G, Perneczky A (1998) Endoscope-assisted brain surgery: part 2analysis of 380 procedures. Neurosurgery 42:226231 Gardner PA, Kassam AB, Thomas A, Snyderman CH, Carrau RL, Mintz AH, Prevedello DM (2008) Endoscopic endonasal resection of anterior cranial base meningiomas. Neurosurgery 63:3652 Gerganov VM, Romansky KV, Bussarsky VA, Noutchev LT, Iliev IN (2005) Endoscope-assisted microsurgery of large vestibular schwannomas. Minim Invasive Neurosurg 48:3943 Greenfield JP, Anand VK, Kacker A, Seibert MJ, Singh A, Brown SM, Schwartz TH (2010) Endoscopic endonasal transethmoidal transcribriform transfovea ethmoidalis approach to the anterior cranial fossa and skull base. Neurosurgery 66:883892 Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A (2006) A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 116:18821886 Hopf NJ, Perneczky A (1998) Endoscopic neurosurgery and endoscope-assisted microneurosurgery for the treatment of intracranial cysts. Neurosurgery 43:13301336 Kawase T, Bertalanffy H, Otani M, Shiobara R, Toya S (1996) Surgical approaches for vertebro-basilar trunk aneurysms located in the midline. Acta Neurochir (Wien) 138:402410

Neurosurg Rev (2011) 34:441455 23. King WA, Wackym PA (1999) Endoscope-assisted surgery for acoustic neuromas (vestibular schwannomas): early experience using the rigid hopkins telescope. Neurosurgery 44:10951102 24. Little KM, Friedman AH, Sampson JH, Wanibuchi M, Fukushima T (2005) Surgical management of petroclival meningiomas: defining resection goals based on risk of neurological morbidity and tumor recurrence rates in 137 patients. Neurosurgery 56:546 559 25. Mathiesen T, Gerlich A, Kihlstrom L, Svensson M, BaggerSjoback D (2007) Effects of using combined transpetrosal surgical approaches to treat petroclival meningiomas. Neurosurgery 60:982991 26. Matthies C, Carvalho G, Tatagiba M, Lima M, Samii M (1996) Meningiomas of the cerebellopontine angle. Acta Neurochir Suppl 65:8691 27. Menovsky T, Grotenhuis JA, de VJ, Bartels RH (1999) Endoscope-assisted supraorbital craniotomy for lesions of the interpeduncular fossa. Neurosurgery 44:106110 28. Nakamura M, Roser F, Jacobs C, Vorkapic P, Samii M (2006) Medial sphenoid wing meningiomas: clinical outcome and recurrence rate. Neurosurgery 58:626639, discussion 29. Nakamura M, Roser F, Struck M, Vorkapic P, Samii M (2006) Tuberculum sellae meningiomas: clinical outcome considering different surgical approaches. Neurosurgery 59:10191028 30. Nakamura M, Struck M, Roser F, Vorkapic P, Samii M (2007) Olfactory groove meningiomas: clinical outcome and recurrence rates after tumor removal through the frontolateral and bifrontal approach. Neurosurgery 60:844852 31. Perneczky A, Fries G (1998) Endoscope-assisted brain surgery: part 1evolution, basic concept, and current technique. Neurosurgery 42:219225 32. Pichierri A, Santoro A, Raco A, Paolini S, Cantore G, Delfini R (2009) Cavernous sinus meningiomas: retrospective analysis and proposal of a treatment algorithm. Neurosurgery 64:10901099 33. Rak R, Sekhar LN, Stimac D, Hechl P (2004) Endoscope-assisted microsurgery for microvascular compression syndromes. Neurosurgery 54:876881 34. Reisch R, Perneczky A (2005) Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery 57:242255 35. Samii M, Tatagiba M, Carvalho GA (1999) Resection of large petroclival meningiomas by the simple retrosigmoid route. J Clin Neurosci 6:2730 36. Samii M, Tatagiba M, Carvalho GA (2000) Retrosigmoid intradural suprameatal approach to Meckel"s cave and the middle fossa: surgical technique and outcome. J Neurosurg 92:235241 37. Schroeder HW, Nehlsen M (2009) Value of high-definition imaging in neuroendoscopy. Neurosurg Rev 32:303308 38. Schroeder HW, Oertel J, Gaab MR (2004) Endoscope-assisted microsurgical resection of epidermoid tumors of the cerebellopontine angle. J Neurosurg 101:227232 39. Seifert V, Raabe A, Zimmermann M (2003) Conservative (labyrinth-preserving) transpetrosal approach to the clivus and petroclival regionindications, complications, results and lessons learned. Acta Neurochir (Wien) 145:631642 40. Sekhar LN, Swamy NK, Jaiswal V, Rubinstein E, Hirsch WE Jr, Wright DC (1994) Surgical excision of meningiomas involving the clivus: preoperative and intraoperative features as predictors of postoperative functional deterioration. J Neurosurg 81:860868 41. Tatagiba M, Matthies C, Samii M (1996) Microendoscopy of the internal auditory canal in vestibular schwannoma surgery. Neurosurgery 38:737740 42. Tatagiba M, Samii M, Matthies C, Vorkapic P (1996) Management of petroclival meningiomas: a critical analysis of surgical treatment. Acta Neurochir Suppl 65:9294

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16. 17.

18.

19.

20.

21.

22.

Neurosurg Rev (2011) 34:441455

455 Miguel A. Arraez, Malaga, Spain In this paper of Schroeder and colleagues, the issue of the real usefulness of the endoscope as adjunct tool for the resection of skull base neoplasms arises. It is important to enhance that the radical removal was done in additional 10% of the cases due to the application of this promising technique. Is also important to make a reference of the context in which the endoscopy has been used: supraorbital keyhole approaches or petrosal/parapetrosal skull base approaches with evident limitations to identify all the hidden aspects of the tumors, with special emphasis in the invasion of the internal auditory canal. The authors very honestly state that the main indication in their experience are those particular situations, found in one third of the overall skull base tumors. Pterional and standard transfrontal approaches (non keyhole) would not benefit from endoscopic assistance. Regarding the dilemma of transcranial versus transnasal removal of tuberculum sellae meningiomas, the authors do prefer the transcranial approach, being still this matter under debate in the medical literature with obvious bias according to everyones experience. Of paramount importance are also the comments about the specific technique for endoscopic assistance in skull base. The possibility of damage (thermal or mechanical) to neurovascular structures with the tip of the endoscope must be taken into account. Regarding the use of 70 lens endoscope, in our opinion really difficult to deal with at the skull base region. In summary, this is a very interesting paper pointing out the advantages of this promising technique allowing in some instances good visualization with less invasive approaches for skull base tumor resection.

Comments
Andr Grotenhuis, Nijmegen, The Netherlands In this study, the authors have recorded the benefit of endoscopic application during microneurosurgical resection of 46 skull base meningiomas over a period of 8 years and 3 months prospectively, and the usefulness of the endoscope was assessed regarding the detection of tumor tissue which was not visible under the microscope as well as the ability to remove tumor tissue under endoscopic visualization. However, in the same study period, 97 additional skull base meningiomas were microsurgically resected without additional use of an endoscope because the authors felt it was not of value. So I have to assume that the authors (with the senior author being a well-known expert in this field) have more or less assessed something that they already knew beforehand, i.e., in which cases the use of an endoscope is most likely to be beneficial. As expected, the application of an endoscope was most useful in the small supraorbital craniotomies. There they found residual tumor which could not be visualized with the operating microscope. In all cases, these tumor remnants were removed under endoscopic vision. But also in other location it was to some extent useful, e.g. in removing tumor parts hidden behind the jugular and suprameatal tubercle as well as in looking into Meckels cave. They also have recorded all technical problems with the endoscopes that occurred during the surgeries. There was no obvious complication related to the application of the endoscope, although they correctly state that it is impossible to rule out completely that some additional trauma to the neurovascular structures occurred while using the endoscope, for example because of the heat at the tip of the endoscope. They nicely describe and also beautifully illustrate how the endoscope is used during such skull base procedures. There have been quite some reports on endoscope-assisted microneurosurgical procedures, but only few publications really deal with such technical details of how to use the endoscope wisely [1,2]. Endoscopic inspection and dissection was mostly done with the aid of a 30 or 45 scope, because manipulations under 70 endoscopes are much more difficult because of the sharp angle of view. From their illustrations (Figs. 1, 2, and 3), I can only see one difference compared to my own endoscope-assisted technique. When the endoscope is fixed in a holding arm and is inside the surgical site, it is very difficult to bring the instruments from the outside into the viewing field of the endoscope, so therefore I always have the microscope still in place and introduce the instruments under direct vision through the microscope until I can see them on the monitor displaying the endoscopic image. However, it is this switch between the two modalities that is rather inconvenient and for this purpose and exoscope has been developed. I can only fully agree with their conclusion that it still remains open whether endoscope assistance will improve the results, however, it definitely reduces surgical trauma. Using endoscopes during microsurgical procedures allows a reduction of the craniotomy size, improves illumination and visualization and enables the surgeon to look around bony corners and important neurovascular structures, thus eliminating or at least reducing the need for skull base drilling as well as brain retraction. References 1. Grotenhuis JA (1995) Endoscope-assisted craniotomy. Techniques in Neurosurgery 1: 201212 2. Grotenhuis JA (1998) Endoscope-assisted removal of skull base tumors. In: Endoscope-assisted microneurosurgery. A concise guidebook, pp. 57100. Uitgeverij Machaon, Nijmegen.

Salvatore Di Maio, Laligam N. Sekhar, Washington, USA Schroeder et al. present a series of 46 of 143 patients with skull base meningiomas treated from 2002 to 2009 in which endoscopic-assisted microsurgical resection was performed. The endoscope was used in 30 cases to identify tumor remnants; and in 26 procedures, tumor resection was carried out using the endoscope as the viewing tool. A gross total resection was performed in 76% of patients, with the remainder having near-total resection. Most of the subtotal resections were in petroclival meningiomas (4/13 gross total resection). No growth of residual tumors was observed over 49 months mean follow-up. Complications included cranial nerve deficits in 20 patients (43%) of which seven are permanent. Four patients developed CSF rhinorrhea post-operatively. Of note, it appears that the authors practice is to perform smaller craniotomies (e.g., supraorbital craniotomies for anterior fossa meningiomas and retrosigmoid craniotomies for petroclival meningiomas), in which the extent of open exposure is limited and thus the endoscope was relied on to improve visualization. It is difficult to interpret the rate of gross total resection in these patients because a further 97 patients with skull base meningiomas were treated concomitantly during the treatment period without the use of the endoscope, however the authors initial results are appealing and the merits of endoscope assistance are well conveyed. We have been using the endoscope routinely for several types of microsurgical operations, including microvascular decompression, aneurysm surgery, and skull base tumors. It is our experience that the endoscope is a valuable tool for visualization of certain blind spots during open microsurgical approaches; however, it has not changed our practice of applying full but refined skull base approaches to such meningiomas for safe but maximal exposure and resection.