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Background: Cavernous sinus (CS) invasion is one of the most unfavorable features of pituitary adenomas. The most widely used classification was proposed by Knosp in 1993 and revised in 2015. The aim of this study is to extend our previous experience by comparing the pre-operative neuroradiological assessment with the intra-operative endoscopic endonasal inspection in order to evaluate the real rate of CS invasion and analyze its correlation with the surgical outcome., Methods: Consecutive patients, who have undergone endoscopic endonasal surgery for a pituitary adenoma with Knosp grade greater than 1, have been included in this study. The intra-operative CS invasion was assesses basing on surgical reports. The surgical outcome has been evaluated with MRI, endocrinological, visual and neurological evaluation have been performed 3 months after surgery and then annually., Results: The series included 402 patients. Male-female ratio was 1:1 and median age was 56 years (range 15-85). We observed that 43% of cases with Knosp grade greater than 1 presented no CS invasion on surgical inspection. Knosp grade 4 was the only one corresponding in all cases to a real CS invasion. Radical tumor removal was achieved in 60%. while endocrinological remission was obtained in 37% of functioning adenomas. Better results were observed for lower Knosp grades., Conclusions: The endoscopic endonasal inspection is the most effective technique to detect CS invasion. Indeed, it can provide a direct visualization of the medial wall, permitting the assessment of its invasion and the management of those cases with diffuse involvement. We confirm that the revision to the Knosp classification has improved its prognostic role.

Study Design: This study evaluates a series of consecutive endoscopic endonasal odontoidectomies performed since 2008 in our center., Objective: The aim of the study was to analyze the outcome and the surgical technique to enlighten advantages and limitations of this procedure., Summary of Background Data: Odontoidectomy represents the treatment of choice in selected cases of basilar invagination. Transoral-transpharyngeal odontoidectomy is the "gold standard" and more experienced technique. Recently, the endoscopic endonasal approach has been proposed as an alternative route., Methods: All patients underwent a pre- and postoperative evaluation of neurological status using physical neurological examination, assessment of American Spinal Injury Association impairment scale score, and neurophysiological investigations. Pre- and postoperative neuroradiological examinations consisted of magnetic resonance imaging, computed tomography, and radiography in flexion and extension. Surgical complications, time of orotracheal extubation and of resumption of oral feeding after surgery were considered, basing on medical records., Results: The series is composed of 5 cases. All cases presented a progressive tetraparesis despite a posterior occipitocervical arthrodesis. Two patients presented with irreducible atlantoaxial subluxation in Down syndrome, whereas the others presented with an atlanto-occipital malformation with platybasia and basilar invagination. No complications were observed. In all except one case, orotracheal intubation was removed immediately at the end of surgery. Oral feeding was resumed 1 day after surgery in all but one case that initially required an orogastric tube. At follow-up (mean: 34.2 mo; range: 3-57 mo), neurological symptoms have been shown to improve in 2 cases and stabilization, arresting the neurological worsening, in 3 cases., Conclusion: Endoscopic endonasal odontoidectomy resulted in a safe, effective, and well-tolerated procedure. From our experience, we conclude that the different approaches for odontoidectomy should be considered to be complementary rather than alternative: the endonasal endoscopic can be advantageous in selected cases presenting some anatomical conditions related (micrognathia and macroglossia) to the oral cavity and to high position of the odontoid.

Object In the last decade the indications for the endoscopic endonasal approach have been progressively expanded to include lesions that have not been traditionally considered amenable to resection through the transsphenoidal route. In this study, the authors analyze their experience with hypothalamic gliomas treated via the endoscopic endonasal approach. Methods Consecutive cases of hypothalamic gliomas treated since 2007 via an endoscopic endonasal approach were reviewed. Preoperative and postoperative neuroimaging as well as endocrinological, neurological, and visual symptoms were analyzed to assess the surgical outcome. Signs and symptoms of hypothalamic dysfunction including body mass index (BMI), memory, sleep-wake rhythm, and polyphagia were prospectively collected pre- and postoperatively to assess hypothalamic function. Quality of life was evaluated using the Katz scale. Results In the initial phase the endoscopic endonasal approach was adopted in 3 cases with a palliative intent, to obtain a biopsy sample or for debulking of the mass followed by radio- or chemotherapy. In 2 later cases it was successfully adopted to achieve gross-total tumor resection. Complications consisted of 2 postoperative CSF leaks, which required an endoscopic endonasal reintervention. Visual deficit improved in 3 cases and normalized in the other 2. Four patients developed diabetes insipidus, and 3 an anterior panhypopituitarism. All patients had a moderate increase in BMI. No patients presented with any other signs of hypothalamic damage, and their quality of life at follow-up is normal. Conclusions Despite the limitations of a short follow-up and small sample, the authors' early experience with the endoscopic endonasal approach has revealed it to be a direct, straightforward, and safe approach to third ventricle astrocytomas. It allowed the authors to perform tumor resection with the same microsurgical technique: dissecting the tumor with 2 hands, performing a central debulking, and controlling the bleeding with bipolar coagulation. The main limitations were represented by some anatomical conditions, such as the position of the chiasm and the anterior communicating artery complex and, finally, by the challenge of watertight plastic repair. To definitively evaluate the role of this approach in hypothalamic gliomas, a comparison with transcranial series would be necessary, but due to the rarity of these cases such a study is still lacking. The authors observed that more aggressive surgery is associated with a worse endocrinological outcome; thus they consider it to be an open question (in particular in prepubertal patients) whether radical removal is an advisable goal for hypothalamic gliomas.

Objective: In the past 2 decades, various extracranial approaches to the cavernous sinus (CS), using either microscopic or endoscopic techniques, have been described. The aim of this study was to describe the distinctive anatomic features of these approaches and compare their efficacy in exposing the sella and parasellar areas., Methods: Ten adult cadaver heads with red latex injected in the arterial system were used. Five different approaches were performed: 1) endonasal microscopic transsphenoidal approach; 2) sublabial microscopic transsphenoidal approach, including its variation described by Fraioli et al. ; 3) transmaxillary microscopic approach; 4) paraseptal endoscopic transsphenoidal approach; and 5) transethmoid-pterygoid-sphenoidal endoscopic approach. The CS exposition was evaluated for each approach and a grading system, which considers surgical maneuverability as well as visualization, was used., Results: The medial CS compartment is well exposed with all endoscopic and microscopic transsphenoidal approaches, but it is insufficiently exposed with the transmaxillary approach. The variation to the sublabial microscopic approach suggested by Fraioli et al. allows its widest microsurgical exposure. The lateral compartment is well visualized with the transmaxillary microscopic and the endoscopic approaches. The major anatomic structures that can limit exposure of the CS lateral compartment are the posterior ethmoid and medial pterygoid process., Conclusion: The sublabial transsphenoidal microscopic approach, with its variations, allows the most versatile extracranial microscopic exposure of the sella and CS. The paraseptal, binostril endoscopic approach allows a very good exposure of the CS; the transethmoid-pterygoid-sphenoidal endoscopic approach achieves the best maneuverability in the lateral compartment of the CS.

Background: This study points out the effectiveness of the endoscopic approach for the treatment of vascular lesions such as angiofibroma, hemangioma, and hemangiopericytoma involving the nose and paranasal sinuses., Methods: We performed a retrospective study at an academic tertiary referral center. Thirteen patients, diagnosed with vascular tumors of the nose and paranasal sinuses were treated endoscopically between February 1996 and July 2003. All patients underwent endonasal endoscopic surgery. Preoperative angiography with embolization was performed in all but two cases., Results: The follow-up of this series varied from 6 to 75 months (mean, 23 months); only one recurrence (8%) was observed in the juvenile angiofibroma group encountered 20 months postoperatively. This recurrence was again treated endoscopically. The average intraoperative blood loss for the removal of the juvenile angiofibroma group was 300 mL and it was 100 mL for the other vascular tumors., Conclusion: Endoscopic treatment alone is an effective approach for the removal of selected cases of vascular tumors. Even in the presence of a lesion with limited intracranial extension, the tumor still may be amenable to an endoscopic approach alone. On the contrary, this is not true if the intracranial extension receives feeding vessels from the internal carotid arterial system.

Objective: The endoscope has recently been applied to the supradiaphragmatic transsphenoidal approach, but only case reports dealing with different pathological features have been described. The authors present their experience with this technique in 10 patients with craniopharyngiomas., Methods: A pure endoscopic endonasal technique was used. From November 1998 through May 2005, four males and six females with a craniopharyngioma, either purely supradiaphragmatic (six patients) or with a significant suprasellar component (four patients), were treated. The tumors had a mean diameter of 2.9 cm (range, 1-4 cm); four patients had a major prechiasmatic component and six had a retrochiasmatic one., Results: Seven total, one subtotal, and two partial resections were obtained. Vision symptoms improved significantly in six out of eight patients. Endocrine function did not improve after surgery, and diabetes insipidus was the most frequent deficit, although it was transient in five out of eight patients. Cerebrospinal fluid leak was the most frequent complication and required reoperation in two patients. Postoperative obesity occurred in two patients. No recurrence has yet been documented in the total resection group. The mean follow-up period is 37 months (range, 3-75 mo)., Conclusion: The endoscopic technique allows results comparable with the best microscopic series. We think that this technique increases the safety of the procedure because of improved vision. Further studies are required to better define the exact location of the tumor with respect to the arachnoidal plane, the extra-arachnoidal craniopharyngioma being the most suitable for a radical removal using a transsphenoidal supradiaphragmatic approach.

Objective: We report our experience with endoscopic transsphenoidal or extended endoscopic transsphenoidal approaches for the treatment of cranial base lesions such as clival chordomas and chondrosarcomas., Methods: Between May 1998 and April 2004, 11 patients (four were recurrences because they previously had been treated with surgery and/or radiotherapy) underwent transnasal transsphenoidal endoscopic surgery for cranial base chordomas and chondrosarcomas at the Neurosurgical Department of Bellaria Hospital in Bologna. The transsphenoidal endoscopic approach and the ethmoid-pterygo-sphenoidal endoscopic approach were used to accomplish resection of the lesions involving the clivus and extending up to the parasellar region and to the petrous apex, or within the cavernous sinus., Results: Patient follow-up periods ranged from 15 to 69 months (mean, 27 mo). Three patients died of chordoma progression at 20, 14, and 10 months, respectively, after endoscopic treatment. One patient experienced two recurrences; the first was treated using a new endoscopic approach, whereas the second, 1 year later, was treated by means of a far lateral approach. Four patients underwent postoperative proton beam radiotherapy, whereas one underwent a conventional megavoltage x-radiation therapy. However, postoperative radiotherapy was not administered in the two patients treated for cranial base chondrosarcoma., Conclusion: The flexibility of this new technique with respect to the classical microscopic transsphenoidal approach permits us to widen the horizon of surgical management of aggressive cranial base tumors such as clival chordomas and chondrosarcomas.

Background: The endoscopic approach can be used successfully for the treatment of benign tumors such as fibroosseous and vascular lesions, pleomorphic adenoma, glioma, meningioma, and schwannoma., Methods: Thirty-three patients diagnosed with benign tumors of the nasal cavity and paranasal sinuses and treated using an endoscopic approach were reviewed retrospectively. The endoscopic approach was simple in 28 cases and associated with an external approach in 5 cases (because of an intracranial extension of the tumor in four patients and its location at the level of the anterior wall of the frontal sinus in the last case)., Results: The resection of the lesions was complete in 32 patients and subtotal in one case. The mean follow-up was 28 months and only two recurrences (6%) were observed in the juvenile angiofibroma group and in the case of the fibrous dysplasia associated to aneurysmal bone cyst, respectively, 20 and 24 months postoperatively., Conclusion: In selected cases, endoscopic surgery can be considered an effective treatment for the resection of benign tumors involving the sinonasal tract.

The transsphenoidal route is the most widely used technique for pituitary adenoma surgery due to its rapidity, good tolerance, effectiveness and low complication rate. These are the parameters we utilized in comparing endoscopic with microscopic transsphenoidal surgery. We reviewed the medical records of 418 patients affected by pituitary adenomas who underwent endoscopic transsphenoidal surgery between May 1998 and December 2004, and in this paper, we present the results of 381 patients who fulfilled the follow-up criteria after a minimum period of 15 months. Our experience confirms the previous data on the rapidity and satisfactory tolerance of the endoscopic procedure. We also confirm the low complication rate, specifying that complications characteristic of the approaching phase were certainly reduced; instead, complications characteristic of tumor removal still remained similar to those reported in the microsurgical literature. The results were comparable with those of the best microsurgical series regarding endosellar lesions, but tumor removal was notably superior when dealing with tumors having an extrasellar extension. The improvement may be explained by the excellent vision of the deep surgical fields due to the endoscope and by the extreme flexibility of the surgical trajectory, mainly due to the absence of the divaricator, giving access to the ramifications of the tumor, otherwise difficult to reach.

Objective: The endoscopic approach can be successfully employed for the treatment of benign tumors such as fibroosseus and vascular lesions, pleomorphic adenomas, gliomas, and schwannomas., Study Design and Setting: Nineteen patients diagnosed with benign tumors of the nasal cavity and paranasal sinuses and treated using an endoscopic approach were retrospectively reviewed. The endoscopic approach was used exclusively in 15 cases and was associated with an external approach in 4 cases (due to an intracranial extension of the tumor in 3 patients and its location at the level of the anterior wall of the frontal sinus in the last case)., Results: The resection of the lesions was radical in 18 patients and subtotal in 1 case. The mean follow-up was 27 months and only 1 recurrence (5%) was observed in the juvenile angiofibroma group 20 months postoperatively., Conclusion: and significance In selected cases, endoscopic surgery can be considered an effective treatment for the resection of benign tumors involving the sinonasal tract.

Schwannomas are tumors that rarely involve the sinonasal tract or the pterygopalatinefossa. Three cases of benign schwannomas originating in the nasal cavity, the nasal-ethmoid, and the pterygopalatine fossa are reported. Surgical treatment is considered the treatment of choice to achieve long-term success. In this study, the effectiveness of the endoscopic endonasal approach is outlined for the diagnosis and treatment of these benign tumors.

Background Meningocele and meningoencephalocele of the lateral wall of the sphenoidal sinus (LWSS) are rare lesions, crossing the borders of multiple disciplines such as ear-nose-throat, maxillofacial, and neurologic surgery. We reviewed our surgical experience to analyze the role of the endoscopic endonasal approach and consider these pathologies from different perspectives. Methods All consecutive cases of meningocele and meningoencephalocele of LWSS operated through an endoscopic endonasal approach from 1998 to 2015 in our institutions were collected. Medical history, focusing on previous episodes of cerebrospinal fluid leak, meningitis or seizures, was considered. The outcome was assessed considering the medical condition and the postoperative neuroimaging. Results The series includes 23 patients (7 male, 16 female). Mean age was 52 years (26–73 years). Eleven cases were meningoencephaloceles and 12 meningoceles. A clear cerebrospinal fluid leak occurred on in 19 patients and was associated with meningitis in 3. Two were presenting a history of epilepsy. No complications were observed, but 1 case presented seizures on waking. At follow-up (mean 84 months, 4–167) each patient is in good clinical condition with no further episodes of leaking or seizures. Conclusions Endoscopic endonasal surgery is a safe and effective approach for meningocele and meningoencephalocele of LWSS; it allows resection of herniated tissue and repair of the osteodural defect. The favorable clinical outcome and the possible effectiveness on seizures lead us to support this approach as first minimally invasive treatment also in presence of epilepsy, as a first low risk epilepsy surgical procedure. [ABSTRACT FROM AUTHOR]