Application of endoscopic transnasal approach combined with microscopic craniotomy in complex skull base tumors with nasal cranial communication

doi:10.3969/j.issn.1672-6731.2023.07.002

Abstract

Abstract:

Objective: To explore the efficacy and safety of endoscopic transnasal approach combined with microscopic craniotomy in the stimultaneous resection of complex skull base tumors with nasal cranial communication, and the protective effect of vascular anastomosis technology in the internal carotid artery (ICA). Methods and Results: From January 2020 to December 2022, the Department of Neurosurgery of Tianjin Huanhu Hospital used endoscopic transnasal approach combined with microscopic craniotomy to treat 9 patients with complex skull base tumors with nasal cranial communication at the same time, while 6 patients were protected by identifying, exposing and shifting the ICA during the craniotomy, and 3 patients underwent petrosal segment of the ICA-radial artery (RA)-bed segment of the ICA bypass on the basis of ICA protection. Among the 9 patients, 8 cases underwent total tumor resection, and one case underwent partial tumor resection; 8 cases[Glasgow Outcome Scale (GOS) level 5] resumed daily life and work at 2 weeks after surgery, one case (GOS level 4) had decreased vision on the affected side but had self- help, and only one case developed intracranial infection 3 d after surgery. Conclusions: Endoscopic transnasal approach combined with microscopic craniotomy for simultaneous resection of complex skull base tumors with nasal cranial communication has a definite therapeutic effect and no serious complications, the application of intraoperative ICA protection and vascular anastomosis technology can effectively reduce intraoperative bleeding and postoperative complications.

Key words: Skull base neoplasms, Endoscopy, Neurosurgical procedures, Carotid artery, internal, Cerebral revascularization

摘要：

目的: 探讨内镜下经鼻入路联合显微镜下开颅手术同期切除复杂鼻颅沟通颅底肿瘤的疗效和安全性，以及血管吻合技术对颈内动脉的保护作用。方法与结果: 2020年1月至2022年12月天津市环湖医院神经外科采用内镜下经鼻入路联合显微镜下开颅手术同期治疗9例复杂鼻颅沟通颅底肿瘤患者，6例通过开颅手术中辨识、显露、移位颈内动脉的方式保护颈内动脉，3例在颈内动脉保护的基础上行颈内动脉岩骨段-桡动脉-颈内动脉床突段搭桥术。8例肿瘤全切除，1例肿瘤大部切除。术后2周，8例恢复日常生活与工作[Glasgow预后分级（GOS）5级]，1例视力减退但生活可自理（GOS分级4级）；仅1例术后3 d发生颅内感染。结论: 内镜下经鼻入路联合显微镜下开颅手术同期切除复杂鼻颅沟通颅底肿瘤疗效确切，且无严重并发症；术中颈内动脉保护及血管吻合技术的应用可有效减少术中出血及术后并发症。

关键词: 颅底肿瘤, 内窥镜检查, 神经外科手术, 颈内动脉, 脑血管重建术

Chen ZHANG, Yan-ming ZHANG, Xiao-guang TONG. Application of endoscopic transnasal approach combined with microscopic craniotomy in complex skull base tumors with nasal cranial communication[J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2023, 23(7): 575-579.

张晨, 张延铭, 佟小光. 内镜下经鼻入路联合显微镜下开颅手术治疗复杂鼻颅沟通颅底肿瘤初探[J]. 中国现代神经疾病杂志, 2023, 23(7): 575-579.

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URL: https://journal11.magtechjournal.com/cjcnn/EN/10.3969/j.issn.1672-6731.2023.07.002

https://journal11.magtechjournal.com/cjcnn/EN/Y2023/V23/I7/575

Figures/Tables 2

Figure 1 Preoperative imaging findings 3D - reconstruction CT of blood vessels showed the tumor surrounding the cavernous sinus segment of the right ICA (Panel 1a). 3D-reconstruction CT skull base bone showed the hyperplasia of the anterior clinoid process (Panel 1b). Anterior- posterior DSA showed the balloon temporarily blocked the blood flow of the right ICA, and no signs of limb weakness, anesthesia, aphasia or changes in consciousness occurred within 30 min. The left ICA compensated well to the right anterior circulation through the anterior communication artery of the Willis circle, and the BOT test was negative (Panel 1c). Anterior-posterior DSA showed anastomosis between the radial artery (shallow location) and ulnar artery (deep location) diverging from the brachial artery and supplying blood to the forearm (Panel 1d).

Figure 2 Intraoperative identification of ICA and vascular bypass surgery Craniotomy was performed under a microscope to remove the right parasellar tumor, the middle skull base bone and the anterior bed process, open the proximal and distal ring of the ICA, expose and free the ICA to the right, and insert a sponge ball (purple indicates) between the optic nerve and the ICA for endoscopic indication of the ICA recess (Panel 2a). Endoscopic visualization of the ICA exposed and displaced after craniotomy through nasal approach (Panel 2b). The ICA with both ends of the tumor blocked was seen during craniotomy (Panel 2c). The anastomosis of ICA petrosal segment-RA-bed segment was observed by 3D-reconstruction CT of skull base bone and blood vessels after bypass surgery. It can be seen that both ends of the transplanted RA were anastomosed to the ICA bed segment (thick arrow indicates) and the rock segment (thin arrow indicates, Panel 2d). Anterior-posterior DSA of bypass surgery showed smooth blood flow of anastomotic vessels (Panel 2e). 3D-reconstruction CT of blood vessels after bypass surgery showed the transplanted RA (purple indicates, Panel 2f).

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