Extradural anterior clinoidectomy in the management of parasellar meningiomas: Analysis of 13 years of experience and literature review

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13 años de experiencia y revisión de la literatura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 706 "Ancho" => 1750 "Tamanyo" => 169573 ] ] "descripcion" => array:1 [ "en" => "(a) Pre-operative MRI where there is a tuberculum sellae meningioma involving the right optic nerve. (b) Reconstruction of the pre-operative CT and (c) post-operative CT where the extent of the resection of the clinoid process and the orbital roof can be observed." ] ] ] "textoCompleto" => "IntroductionThe anterior clinoid process (ACP) is the medial portion of the lesser sphenoid wing. Its anatomical location is extremely important due to its relationship with the optic nerve, the internal carotid artery and other parasellar neurovascular structures.<a class="elsevierStyleCrossRef" href="#bib0200">1</a>The extradural anterior clinoidectomy (EAC) is a key microsurgical technique that facilitates the resection of tumours and clipping of aneurysms located in the parasellar and suprasellar regions.<a class="elsevierStyleCrossRefs" href="#bib0205">2,3</a> From the many advantages that this procedure offers us, what stands out is that it reduces the need for the retraction of brain parenchyma and broadens intraoperative exposure of the internal carotid artery (×1.5) and of the optic nerve (×2), tripling the size of the opticocarotid triangle.<a class="elsevierStyleCrossRef" href="#bib0215">4</a> Several authors assert that it also improves post-operative visual outcomes.<a class="elsevierStyleCrossRefs" href="#bib0210">3,5,6</a> Additionally, it may favour early devascularisation of the tumour, and given that in a high percentage of patients the ACP bone is infiltrated by the tumour, it may help to prevent tumour recurrences in the region.<a class="elsevierStyleCrossRef" href="#bib0230">7</a>While anterior clinoidectomy was first described by Drake in 1968 as part of the approach to carotid-ophthalmic aneurysms,<a class="elsevierStyleCrossRef" href="#bib0235">8</a> the first description of the extradural technique was not until 1985 by Dolenc.<a class="elsevierStyleCrossRef" href="#bib0205">2</a>Despite the advances and modifications to the technique, there is currently no consensus regarding the extradural or intradural execution of the procedure nor scientific evidence that supports its routine use or use in selected cases. The purpose of this article is to present our experience in performing EAC as part of the management of skull base meningioma (clinoidal, medial sphenoid wing, cavernous sinus and tuberculum sellae meningiomas). We analysed our series of cases highlighting visual outcomes, resection rates and post-operative complications. Additionally, we carried out an analysis of the main indications for EAC, the techniques used to execute it and its advantages and disadvantages with regard to intradural anterior clinoidectomy. To our knowledge, it is one of the longest series with the one of the longest follow-up periods published to date for resection of meningiomas.Material and methodsA bibliographic search was carried out for articles published on EAC. The key words used were “anterior clinoidectomy” and “extradural anterior clinoidectomy”. Articles written in English and Spanish between 1997 and 2017 were included. A total of 123 articles were reviewed.We carried out a retrospective analysis of the EACs conducted at our site as part of the management of skull base meningiomas with involvement of the parasellar region from the period 2003 to 2015.We classified the meningiomas according to the predominant location of the tumour. In this way, we divided the meningiomas into anterior clinoidectomy, medial sphenoid wing, cavernous sinus and tuberculum sellae. We did not use any further classification described in the literature on meningiomas such as the Al-Mefty scale, since we perceive that there is a high interobserver variability and in many cases it is not possible to determine the exact origin of the tumour.Each patient was examined clinically, with neurological foci being assessed before intervention, during their hospital stay and subsequently in outpatient follow-up. An ophthalmologist performed a pre-operative campimetry and a visual acuity assessment. The visual state was compared with the record at 3 months after the intervention. We differentiated between improvement, stability and visual deterioration, assessing visual acuity and campimetric defects separately.A brain MRI and skull base CT were conducted on all patients before the surgical intervention, as well as a follow-up cranial CT in the immediate post-operative period and a follow-up MRI within the first 3 months after surgery. The tumour resection was assessed on the brain MRI carried out in these 3 months and categorised as total, subtotal (>80%) or partial (<80%)resection. Subsequently, annual MRIs were conducted, the patients considered to be dischargeable after 10 years with no radiological evidence of recurrence.The surgical technique used for the resection of the clinoid process was Dolenc's, including the recent modifications<a class="elsevierStyleCrossRefs" href="#bib0205">2,9,10</a>: after performing the pterional or orbitozygomatic approach, the orbital and roof dura maters were dissected under microscopic visualisation. After a partial section of the meningo-orbital band, the ACP was exposed. The sphenoid wing was then reamed with a diamond burr under continuous irrigation, normally to 1cm of the distal medial edge of the ACP. The resection included part of the orbital roof and superior orbital fissure in those cases where lateral bone exposure to the ACP was necessary, depending on the nature and extent of the injury to be treated, but was not routinely carried out (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The ACP was reamed from lateral to medial, leaving a thin layer of cortical bone for protection, which was dissected and taken away as a final step. In most cases, the falciform ligament and the optic nerve sheath were opened intradurally after the bone reaming, before carrying out the tumour resection. In cases in which there was bleeding through the venous channels that connect the ACP cancellous bone with the cavernous sinus, it was controlled with fibrin glue or with haemostatic agents.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>ResultsThe total number of patients recorded was 53, with 81.1% women (43 women and 10 men). The mean age was 59.5 years (range 29–80 years). The most frequent tumours were anterior clinoidal meningiomas (33.9%), followed by medial sphenoid wing meningiomas (28.3%). 24.5% of patients were operated on for tuberculum sellae meningiomas and 13.2% for cavernous sinus meningiomas (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The most common initial clinical symptoms were decreased visual acuity (45.3%) followed by headache (22.6%). 17.0% of patients presented with campimetric impairment, 17.0% exophthalmos, 11.3% oculomotor nerve paresis, 15.1% seizure crisis, 7.5% trigeminal nerve damage and 3.8% hormone dysfunction. In 3.8% of cases the diagnosis was incidental (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Taking into account that EAC can be performed via different routes of approach depending on the pathology to be treated, in our series, the pterional approach was used for 88.7% of patients, followed by the orbitozygomatic in the remaining 11.3%.There was total tumour removal in 67.9% of cases (in 92.3% of tuberculum sellae meningiomas, 61.1% of anterior clinoid meningiomas, in 60.0% of medial sphenoid wing meningiomas and in 57.1% of meningiomas located in the cavernous sinus), with subtotal removal (greater than 80%) in the remaining 32.1%.Following surgical intervention, in all the patients resolution of the exophthalmos clinical symptoms was observed, as well as control of seizure crisis and improvement in headache and dizziness.Visual outcomesRegarding the visual deficits (decreased visual acuity or campimetric impairment), if we analyse the results overall, 67.9% of patients presented with clinical stability, 22.6% improvement and 9.4% worsening of the visual impairments.45.3% of patients presented with decreased post-operative visual acuity: 50.0% of those remained stable following the surgery, 12.5% worsened and 37.5% improved. 54.7% of patients did not present with decreased visual acuity: 96.6% of those remained stable following the intervention, 3.4% experienced decreased post-operative visual acuity. 17.0% of patients had pre-surgical campimetric defects: 44.4% of those remained stable following the surgery, 11.1% worsened and 44.4% improved. 83.0% of patients did not present with pre-operative campimetric defects: 97.7% of those remained stable following the intervention and 2.3% experienced new campimetric defects following the surgery (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The grade of tumour resection (total vs subtotal) did not significantly influence the post-operative visual outcomes or visual acuity (p=0.71), or campimetric impairment (p=0.53). The location of the meningiomas did not significantly influence post-operative visual acuity either (p=0.67), but with regard to campimetric impairment, tuberculum sellae meningiomas experienced a significantly higher percentage of improvement over the other tumours (p=0.002).Complications24.5% of patients presented with transient paresis of the third cranial nerve and 1.9%, permanent (3.8% of the patients presented with pre-operative paresis). Infection was observed in 5.7% of surgical wounds, requiring re-intervention in 2 out of 3 of patients for this reason. The rate of post-operative cerebrospinal fluid fistulas was 3.8%, with satisfactory resolution experienced with rest and external lumbar drainage, with no re-intervention required for any patient. No internal carotid injuries were reported. The mortality rate was 0%.The mean follow-up was 82.3 months (range 151–156). 9.4% of patients required re-intervention: 3.8% due to growth of tumour remnants and 5.6% due to tumour recurrence.DiscussionAnatomyThe anterior clinoid process is a small, conical process that projects from the posteromedial edge of the lesser wing of the sphenoid. Its anatomy, as well as its relationship with the adjacent structures, has been described in detail in numerous articles.<a class="elsevierStyleCrossRefs" href="#bib0200">1,9,11,12</a> Along with the orbital part of the frontal bone, the clinoid process covers the orbital roof and lateral wall of the optic canal.<a class="elsevierStyleCrossRefs" href="#bib0200">1,13</a>It is important to point out the role of the pre-operative CT to identify certain types of anatomical variants, such as the carotico-clinoid foramen between the anterior and middle clinoid processes (14–27%) or the interclinoid bony bridge between anterior and posterior clinoid processes (3–9%),<a class="elsevierStyleCrossRefs" href="#bib0200">1,14</a> which would impose a limitation when performing a purely extradural clinoidectomy. Additionally, up to 30% of patients in the series had pneumatisation of the clinoids,<a class="elsevierStyleCrossRefs" href="#bib0265">14,15</a> which should be taken into account to prevent incidental openings of the paranasal mucosa and its consequential complications (rhinorrhoea, mucocele, pneumocephalus, etc.),<a class="elsevierStyleCrossRef" href="#bib0270">15</a> cerebrospinal fluid fistula may have been observed in more than 40% of these patients.<a class="elsevierStyleCrossRef" href="#bib0275">16</a> Different scales to assess the pneumatisation of the clinoids have been described: the most frequently used would be the proposal by Mikami et al.,<a class="elsevierStyleCrossRef" href="#bib0270">15</a> Type I: posterior stem approach (74%); Type II: anterior stem approach (15%); or Type III: both (11%). Another common scale, but whose clinical application has been challenged would be the proposal by Abuzayed et al.,<a class="elsevierStyleCrossRef" href="#bib0280">17</a> Type I: less than 50% (the most common); Type II: more than 50%, or Type III: total.Extradural vs intradural techniqueDespite the indisputable requirement for carrying out a resection of the anterior clinoids when addressing various skull base tumours, the optimal surgical strategy has traditionally been a source of controversy. Both the extradural and intradural approaches have their supporters and have been extensively discussed in the literature. When comparing them, we can say that the EAC is technically simpler and quicker,<a class="elsevierStyleCrossRef" href="#bib0210">3</a> and that it allows for a wider exposure and an earlier devascularisation of the tumour. Additionally, on conserving the dura mater as protection, it is safer,<a class="elsevierStyleCrossRef" href="#bib0210">3</a> the need for intradural dissection is more limited<a class="elsevierStyleCrossRef" href="#bib0285">18</a> and the deposit of bone particles generated during reaming at the intradural level is avoided, something that has been associated with post-operative headache.<a class="elsevierStyleCrossRef" href="#bib0290">19</a> In those cases where the clinoids are pneumatised, the rates of cerebrospinal fluid fistulas recorded in the literature following an EAC are fewer.<a class="elsevierStyleCrossRef" href="#bib0245">10</a>The advantages of intradural clinoidectomy would be the direct view of important intradural neurovascular structures and the possibility of adjusting the grade of extent of the clinoidectomy to individual needs.<a class="elsevierStyleCrossRefs" href="#bib0295">20–22</a> In the same way, a concept introduced by Hernesniemi in 2011 is the adapted clinoidectomy, with the capacity to adjust the grade of resection of the clinoids to the needs of each case. While this technique is usually carried out intradurally, it can also be carried out extradurally. Accordingly, we can differentiate between four grades of resection: minimum (less than 1/3), partial (1/3), subtotal (2/3) and total (3/3).<a class="elsevierStyleCrossRef" href="#bib0310">23</a> Hybrid methods have also been described, which try to combine the best of each technique.<a class="elsevierStyleCrossRef" href="#bib0315">24</a>Various authors have concluded that extradural clinoidectomy is superior to intradural clinoidectomy in most cases and can be used routinely for most supra- and parasellar injuries with minimal associated complications.<a class="elsevierStyleCrossRefs" href="#bib0245">10,25,26</a>Approach, indications and surgical techniqueEAC can be carried out via different approaches depending on the pathology to be treated, the most prevalent in the literature being the pterional approach, followed by the orbitozygomatic and lateral supraorbital approaches.<a class="elsevierStyleCrossRef" href="#bib0310">23</a>We can currently identify two streams supporting routine clinoidectomy (tuberculum sellae, anterior clinoid process, cavernous sinus or optic canal meningiomas) and those that are conducted in selected cases<a class="elsevierStyleCrossRefs" href="#bib0270">15,23</a>: when the tumour invades the optic canal or encompasses the internal carotid artery (the objective would be to achieve good proximal control, as well as safe vascular and optic nerve dissection) or when there is prominent hyperostosis of the anterior clinoid process or the tumour is firmly attached to it (with coagulation being insufficient to achieve a total tumour resection). A study recently published in 2015 recommends its routine use, claiming that up to 1/4 of the patients in whom the clinoids appeared not to be invaded by the tumour, tested positive in anatomical pathology for tumour cells.<a class="elsevierStyleCrossRef" href="#bib0230">7</a> Additionally, in the event of a recurring tumour, as the decompression of the optic nerve has already been performed, theoretically the visual deterioration of the patient can be delayed.<a class="elsevierStyleCrossRef" href="#bib0330">27</a> At our site, we use routine EAC for those meningiomas located in the parasellar region.Different methods have been described for carrying out bone resection, each with its advantages and drawbacks, from conventional reaming to more novel methods such as ultrasonic aspirators. None of the techniques in the literature is superior to another. Regarding reaming, both indirect (thermal) and direct (mechanical) injuries have been observed in the adjacent neurovascular structures, while continuous irrigation and the use of a diamond burr (avoids injury to the paranasal sinus mucosa) have been associated with a decrease in rates of associated complications.<a class="elsevierStyleCrossRef" href="#bib0200">1</a> Ultrasonic bone aspirators, having no rotating component, are presented as a more stable and safer method<a class="elsevierStyleCrossRef" href="#bib0335">28</a>; however, this is a more expensive, slower system with cases of intracranial nerve injury and spinal cord injury having been described.<a class="elsevierStyleCrossRefs" href="#bib0300">21,29</a> Resections can also be conducted using a Kerrison rongeur<a class="elsevierStyleCrossRef" href="#bib0345">30</a> which involve a lower cost and shorter time, but can cause compression injuries. Lastly, it is worth mentioning en bloc resection, both intradurally<a class="elsevierStyleCrossRef" href="#bib0350">31</a> and extradurally,<a class="elsevierStyleCrossRef" href="#bib0340">29</a> taking into account in this case the difficulty posed for accuracy of the direction of the fracture line. At our site we use diamond burr under continuous irrigation.ComplicationsAmong the complications associated with this technique we can highlight the following:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Optic nerve injury (decrease in visual acuity, campimetric defects) (0–13%).<a class="elsevierStyleCrossRefs" href="#bib0210">3,32,33</a></li><li class="elsevierStyleListItem" id="lsti0010">2.Third cranial nerve paresis<a class="elsevierStyleCrossRefs" href="#bib0355">32,33</a>:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">1.Intradural clinoidectomy: 10–75% transient, 4–13% permanent.<a class="elsevierStyleCrossRef" href="#bib0365">34</a></li><li class="elsevierStyleListItem" id="lsti0020">2.EAC 8–14% transient, 0–5% permanent.<a class="elsevierStyleCrossRef" href="#bib0210">3</a></li></ul></li><li class="elsevierStyleListItem" id="lsti0025">3.Internal carotid artery injury (C5, C6).<a class="elsevierStyleCrossRefs" href="#bib0210">3,33</a></li><li class="elsevierStyleListItem" id="lsti0030">4.Pneumocephalus.<a class="elsevierStyleCrossRefs" href="#bib0210">3,33</a></li><li class="elsevierStyleListItem" id="lsti0035">5.Aneurysm rupture (when clinoidectomy is part of the approach).<a class="elsevierStyleCrossRefs" href="#bib0260">13,27</a></li><li class="elsevierStyleListItem" id="lsti0040">6.Incidental opening of the paranasal sinuses (above all, the sphenoid sinus, but also the ethmoid sinus) 2.7–7%.<a class="elsevierStyleCrossRefs" href="#bib0210">3,15,23,33</a></li></ul>With regard to the opening of the paranasal sinuses, the potential resulting complications are cerebrospinal fluid leakage, pneumocephalus, formation of mucocele and infection. There are authors who support the routine use of fibrin glue+muscle+haemostatic patch (Tachosil®) to seal possible communications.<a class="elsevierStyleCrossRef" href="#bib0310">23</a> However, most girdle the intra-operative repair with different materials (muscle, fat, oxycellulose, fibrin glue, etc.) in cases in which the communication is observed intra-operatively. Some authors also consider cerebrospinal fluid fistula to be inevitable when the clinoids are pneumatised.<a class="elsevierStyleCrossRefs" href="#bib0210">3,15</a> The treatment of the fistula can be conservative with rest, or an external lumbar drain can be inserted, or the patient can undergo surgical reintervention. One technique described in 2006 (M. Lawton) to repair the sphenoid sinus opening would be the so-called “yo-yo technique” which consists of inserting a temporal muscle fragment tied at its midpoint in the sphenoid sinus and subsequently withdrawing it to the subarachnoid space, creating a plug (the percentage of fistulas observed with this technique was 0%).<a class="elsevierStyleCrossRef" href="#bib0370">35</a>Our series of patients with extradural anterior clinoidectomyOur results agree with the series previously published in the literature, in which it has been described that the tumours of the anterior and middle fossa with proximity to the optic canal alter visual function before surgical intervention in 35–70% of cases.<a class="elsevierStyleCrossRefs" href="#bib0375">36,37</a> Most of the studies recommend early EAC with decompression of the optic nerve to achieve better post-operative visual recuperation. This recommendation is based mainly on the fact that the initial release of the optic nerve allows it to be managed more safely during the subsequent tumour resection.<a class="elsevierStyleCrossRefs" href="#bib0375">36–38</a>Our main motivation for conducting EAC was impairment of the ACP by the meningioma and the compression of any part of the optical path, whether it be the optic nerve or chiasm. In the cases of impairment of the ACP, we consider EAC to be very useful because in this way we achieve early devascularisation of the tumour and we remove the bone that is infiltrated by tumour on many occasions. The EAC also allows for decompression and manipulation of the optic nerve in an initial phase of surgery, opening the falciform ligament and it means the nerve can move with greater freedom, reducing the possibility of it being injured during the tumour resection manoeuvres. In cases in which the tumour has a prime location in the region of the tuberculum sellae, with its consequential proximity to the chiasm and optic canal, we believe that the decompression and early release of the optic nerve most affected by campimetry allows for its manipulation to avoid new injury during the removal of the meningioma. We use the same reasoning for meningiomas that originate in the medial sphenoid wing or cavernous sinus, and that come into contact with or are in the vicinity of the ipsilateral optic nerve.Despite the advances in techniques and improvements in microsurgical material, the incidence of post-operative visual deterioration, although having improved with the passage of time, still affects a considerable number of patients. Post-operative results are defined by the extent of the resection as well as extent of the decompression of the optic nerve through the unroofing of the optic canal and anterior clinoidectomy. Pre-operative visual state, age, duration and severity of visual symptoms, presence of optic atrophy and the size of the tumour have been identified as prognostic factors.<a class="elsevierStyleCrossRefs" href="#bib0210">3,16,38</a> Sade and Lee found an important degree of correlation between the presence of hypertrophy of the anterior clinoid process and the occupation of the optic canal in meningiomas of the tuberculum sellae.<a class="elsevierStyleCrossRef" href="#bib0390">39</a> In our series, we did not find a statistically significant relationship between the grade of tumour resection and the post-operative visual outcomes. However, meningiomas of the tuberculum sellae experienced a post-operative percentage of improvement of campimetric impairments, which was significantly higher than for the rest of the tumours (p=0.002).In our series, 24.5% of patients presented with temporary paresis of the third cranial nerve and 1.9% had permanent paresis (3.8% of the patients presented with pre-operative paresis), although we consider again, in agreement with the literature, that this complication could be associated with the location and size of the tumour rather than the anterior clinoidectomy itself.<a class="elsevierStyleCrossRef" href="#bib0320">25</a>Based on the above, and in our experience, we believe that post-operative visual changes are related to pre-operative visual function and other prognostic factors cited above, and that EAC would help to achieve a good post-operative visual outcome.ConclusionsIn our experience, EAC is a safe technique that facilitates the resection of the meningiomas located in the parasellar area, helps to achieve early tumour devascularisation, reduces the need for retraction of the brain parenchyma and could play a positive role in the preservation of visual function and the appearance of tumour recurrences in the ACP. There is no scientific evidence that various factors, such as the opening of the superior orbital fissure, the intradural pathway or the extradural pathway, adapted clinoidectomy, or the instruments used to carry out the bone resection affect the visual outcomes following anterior clinoidectomy.Conflicts of interestNone." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1077093" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1023133" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1077094" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1023134" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Visual outcomes" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Complications" ] ] ] 7 => array:3 [ "identificador" => "sec0030" "titulo" => "Discussion" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Anatomy" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Extradural vs intradural technique" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Approach, indications and surgical technique" ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "Complications" ] 4 => array:2 [ "identificador" => "sec0055" "titulo" => "Our series of patients with extradural anterior clinoidectomy" ] ] ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-09-30" "fechaAceptado" => "2018-04-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1023133" "palabras" => array:4 [ 0 => "Parasellar meningiomas" 1 => "Extradural anterior clinoidectomy" 2 => "Visual outcomes" 3 => "Anterior clinoid process" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1023134" "palabras" => array:4 [ 0 => "Meningiomas paraselares" 1 => "Clinoidectomía anterior extradural" 2 => "Resultados visuales" 3 => "Apófisis clinoides anterior" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Background and aimThe extradural anterior clinoidectomy (EAC) is a key microsurgical technique that facilitates the resection of tumours located in the parasellar region. There is currently no consensus regarding the execution of the procedure via extradural or intradural nor scientific evidence that supports its routine use. The purpose of this article is to expose our experience in performing EAC as part of the management of the parasellar meningiomas. Materials and methodsA retrospective analysis of the EAC for parasellar meningioma resection performed in our centre between 2003 and 2015 was done. A total of 53 patients were recorded. We analysed our series focusing on visual outcomes, resection rates and complications. Through an extensive bibliographic research, we discussed the advantages and disadvantages of the EAC, technical considerations, comparison with the intradural clinoidectomy and its visual impact. ResultsThe most frequent tumours were anterior clinoidal meningiomas (33.9%). The most common initial symptoms were decreased visual acuity (45.3%) and headache (22.6%). A gross total resection was achieved in 67.9%, being subtotal in the remaining 32.1%. Regarding the visual deficits 67.9% of the patients presented clinical stability, 22.6% improvement and 9.4% worsening. The degree of tumour resection did not significantly influence post-surgical visual outcomes, either visual acuity (p=0.71) or campimetric alterations (p=0.53). 24.5% of the patients experienced III nerve transient paresis and 1.9% permanent. The postoperative cerebrospinal fluid leak rate was 3.8%. Mortality rate was 0%. The mean follow-up was 82.3 months. ConclusionsIn our experience, EAC is a safe technique that facilitates the resection of the meningiomas located in the parasellar area, helps to achieve early tumour devascularisation, reduces the need for retraction of the cerebral parenchyma and could play a positive role in the preservation of visual function and the appearance of tumour recurrences in the anterior clinoid process (ACP)." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Antecedentes y objetivoLa clinoidectomía anterior extradural (CaE) es una técnica microquirúrgica clave que facilita la resección de tumores localizados en la región paraselar. Actualmente, no existe consenso de la ejecución vía extradural o intradural, o evidencia científica que apoye su uso de manera rutinaria. El propósito de este artículo es exponer nuestra experiencia en la realización de la CaE como parte del manejo de los meningiomas paraselares. Materiales y métodosSe realizó un análisis retrospectivo de las CaE empleadas en las resecciones de meningiomas paraselares realizadas en nuestro centro entre los años 2003 y 2015. Se registraron un total de 53 pacientes. Realizamos un análisis de nuestra serie de casos, enfocándonos en los resultados visuales, las tasas de resección y las complicaciones postoperatorias. A través de una revisión bibliográfica, se discuten las ventajas e inconvenientes de la CaE, consideraciones técnicas, comparación con la clinoidectomía anterior intradural e impacto visual. ResultadosEl tipo de tumor más frecuente fueron los meningiomas de clinoides anterior (33,9%). Los síntomas iniciales más frecuentes fueron la disminución de la agudeza visual (45,3%) y la cefalea (22,6%). La resección tumoral total se consiguió en el 67,9% de los casos, siendo subtotal en el restante 32,1%. Con respecto a los déficits visuales, el 67,9% de los pacientes presentaron estabilidad clínica, el 22,6% mejoraron y el 9,4% experimentaron empeoramiento. El grado de resección tumoral no influyó de manera significativa en los resultados visuales posquirúrgicos, ni en la agudeza visual (p=0,71) ni en los déficits campimétricos (p=0,53). El 24,5% de los pacientes experimentaron paresia del III par transitoria y el 1,9%, permanente. La tasa de fístula de líquido cefalorraquídeo postoperatoria fue del 3,8%. La mortalidad fue del 0%. El periodo medio de seguimiento fue de 82,3 meses. ConclusionesEn nuestra experiencia, la CaE es una técnica segura que facilita la resección de los meningiomas localizados en la región paraselar, favorece la desvascularización temprana del tumor, reduce la necesidad de retracción del parénquima cerebral y podría ejercer un papel positivo en la preservación de la función visual y en la aparición de recidivas tumorales en la apófisis clinoides anterior (ACa)." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Salgado López L, Muñoz Hernández F, Asencio Cortés C, Tresserras Ribó P, Álvarez Holzapfel MJ, Molet Teixidó J. Clinoidectomía anterior extradural en el manejo de meningiomas paraselares: análisis de 13 años de experiencia y revisión de la literatura. Neurocirugia. 2018;29:225–232." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 706 "Ancho" => 1750 "Tamanyo" => 169573 ] ] "descripcion" => array:1 [ "en" => "(a) Pre-operative MRI where there is a tuberculum sellae meningioma involving the right optic nerve. (b) Reconstruction of the pre-operative CT and (c) post-operative CT where the extent of the resection of the clinoid process and the orbital roof can be observed." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 658 "Ancho" => 1667 "Tamanyo" => 44132 ] ] "descripcion" => array:1 [ "en" => "Type of meningioma." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Initial symptomatology \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Decreased visual acuity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (45.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Campimetric defects \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (17.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Headache \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (22.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Exophthalmos \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (17.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oculomotor nerve damage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (11.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Seizure crisis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (15.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trigeminal nerve damage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (7.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hormone dysfunction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Incident \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1838569.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Initial symptomatology." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-operative visual acuity impairment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Stability \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Worsening \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Improvement \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes: 24 (45.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (50.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (12.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (37.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No: 29 (54.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (96.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (3.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1838570.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-operative campimetric defects \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Stability \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Worsening \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Improvement \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes: 9 (17.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (44.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (11.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (44.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No: 44 (83.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 (97.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1838571.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Visual outcomes." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:39 [ 0 => array:3 [ "identificador" => "bib0200" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical anatomy of the anterior clinoid process" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. 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Extradural anterior clinoidectomy in the management of parasellar meningiomas: Analysis of 13 years of experience and literature review

Clinoidectomía anterior extradural en el manejo de meningiomas paraselares: análisis de 13 años de experiencia y revisión de la literatura

Laura Salgado López

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lsalgado@santpau.cat

Corresponding author.

, Fernando Muñoz Hernández, Carlos Asencio Cortés, Pere Tresserras Ribó, María Jesús Álvarez Holzapfel, Joan Molet Teixidó

Departamento de Neurocirugía, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The anterior clinoid process &#40;ACP&#41; is the medial portion of the lesser sphenoid wing&#46; Its anatomical location is extremely important due to its relationship with the optic nerve&#44; the internal carotid artery and other parasellar neurovascular structures&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The extradural anterior clinoidectomy &#40;EAC&#41; is a key microsurgical technique that facilitates the resection of tumours and clipping of aneurysms located in the parasellar and suprasellar regions&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">2&#44;3</span></a> From the many advantages that this procedure offers us&#44; what stands out is that it reduces the need for the retraction of brain parenchyma and broadens intraoperative exposure of the internal carotid artery &#40;&#215;1&#46;5&#41; and of the optic nerve &#40;&#215;2&#41;&#44; tripling the size of the opticocarotid triangle&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">4</span></a> Several authors assert that it also improves post-operative visual outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">3&#44;5&#44;6</span></a> Additionally&#44; it may favour early devascularisation of the tumour&#44; and given that in a high percentage of patients the ACP bone is infiltrated by the tumour&#44; it may help to prevent tumour recurrences in the region&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">While anterior clinoidectomy was first described by Drake in 1968 as part of the approach to carotid-ophthalmic aneurysms&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">8</span></a> the first description of the extradural technique was not until 1985 by Dolenc&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite the advances and modifications to the technique&#44; there is currently no consensus regarding the extradural or intradural execution of the procedure nor scientific evidence that supports its routine use or use in selected cases&#46; The purpose of this article is to present our experience in performing EAC as part of the management of skull base meningioma &#40;clinoidal&#44; medial sphenoid wing&#44; cavernous sinus and tuberculum sellae meningiomas&#41;&#46; We analysed our series of cases highlighting visual outcomes&#44; resection rates and post-operative complications&#46; Additionally&#44; we carried out an analysis of the main indications for EAC&#44; the techniques used to execute it and its advantages and disadvantages with regard to intradural anterior clinoidectomy&#46; To our knowledge&#44; it is one of the longest series with the one of the longest follow-up periods published to date for resection of meningiomas&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">A bibliographic search was carried out for articles published on EAC&#46; The key words used were &#8220;anterior clinoidectomy&#8221; and &#8220;extradural anterior clinoidectomy&#8221;&#46; Articles written in English and Spanish between 1997 and 2017 were included&#46; A total of 123 articles were reviewed&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We carried out a retrospective analysis of the EACs conducted at our site as part of the management of skull base meningiomas with involvement of the parasellar region from the period 2003 to 2015&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We classified the meningiomas according to the predominant location of the tumour&#46; In this way&#44; we divided the meningiomas into anterior clinoidectomy&#44; medial sphenoid wing&#44; cavernous sinus and tuberculum sellae&#46; We did not use any further classification described in the literature on meningiomas such as the Al-Mefty scale&#44; since we perceive that there is a high interobserver variability and in many cases it is not possible to determine the exact origin of the tumour&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Each patient was examined clinically&#44; with neurological foci being assessed before intervention&#44; during their hospital stay and subsequently in outpatient follow-up&#46; An ophthalmologist performed a pre-operative campimetry and a visual acuity assessment&#46; The visual state was compared with the record at 3 months after the intervention&#46; We differentiated between improvement&#44; stability and visual deterioration&#44; assessing visual acuity and campimetric defects separately&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A brain MRI and skull base CT were conducted on all patients before the surgical intervention&#44; as well as a follow-up cranial CT in the immediate post-operative period and a follow-up MRI within the first 3 months after surgery&#46; The tumour resection was assessed on the brain MRI carried out in these 3 months and categorised as total&#44; subtotal &#40;&#62;80&#37;&#41; or partial &#40;&#60;80&#37;&#41;resection&#46; Subsequently&#44; annual MRIs were conducted&#44; the patients considered to be dischargeable after 10 years with no radiological evidence of recurrence&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The surgical technique used for the resection of the clinoid process was Dolenc&#39;s&#44; including the recent modifications<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">2&#44;9&#44;10</span></a>&#58; after performing the pterional or orbitozygomatic approach&#44; the orbital and roof dura maters were dissected under microscopic visualisation&#46; After a partial section of the meningo-orbital band&#44; the ACP was exposed&#46; The sphenoid wing was then reamed with a diamond burr under continuous irrigation&#44; normally to 1<span class="elsevierStyleHsp" style=""></span>cm of the distal medial edge of the ACP&#46; The resection included part of the orbital roof and superior orbital fissure in those cases where lateral bone exposure to the ACP was necessary&#44; depending on the nature and extent of the injury to be treated&#44; but was not routinely carried out &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The ACP was reamed from lateral to medial&#44; leaving a thin layer of cortical bone for protection&#44; which was dissected and taken away as a final step&#46; In most cases&#44; the falciform ligament and the optic nerve sheath were opened intradurally after the bone reaming&#44; before carrying out the tumour resection&#46; In cases in which there was bleeding through the venous channels that connect the ACP cancellous bone with the cavernous sinus&#44; it was controlled with fibrin glue or with haemostatic agents&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">The total number of patients recorded was 53&#44; with 81&#46;1&#37; women &#40;43 women and 10 men&#41;&#46; 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in our series&#44; the pterional approach was used for 88&#46;7&#37; of patients&#44; followed by the orbitozygomatic in the remaining 11&#46;3&#37;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">There was total tumour removal in 67&#46;9&#37; of cases &#40;in 92&#46;3&#37; of tuberculum sellae meningiomas&#44; 61&#46;1&#37; of anterior clinoid meningiomas&#44; in 60&#46;0&#37; of medial sphenoid wing meningiomas and in 57&#46;1&#37; of meningiomas located in the cavernous sinus&#41;&#44; with subtotal removal &#40;greater than 80&#37;&#41; in the remaining 32&#46;1&#37;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Following surgical intervention&#44; in all the patients resolution of the exophthalmos clinical symptoms was observed&#44; as well as control of seizure crisis and improvement in headache and dizziness&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Visual outcomes</span><p id="par0080" class="elsevierStylePara elsevierViewall">Regarding the visual deficits &#40;decreased visual acuity or campimetric impairment&#41;&#44; if we analyse the results overall&#44; 67&#46;9&#37; of patients presented with clinical stability&#44; 22&#46;6&#37; improvement and 9&#46;4&#37; worsening of the visual impairments&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">45&#46;3&#37; of patients presented with decreased post-operative visual acuity&#58; 50&#46;0&#37; of those remained stable following the surgery&#44; 12&#46;5&#37; worsened and 37&#46;5&#37; improved&#46; 54&#46;7&#37; of patients did not present with decreased visual acuity&#58; 96&#46;6&#37; of those remained stable following the intervention&#44; 3&#46;4&#37; experienced decreased post-operative visual acuity&#46; 17&#46;0&#37; of patients had pre-surgical campimetric defects&#58; 44&#46;4&#37; of those remained stable following the surgery&#44; 11&#46;1&#37; worsened and 44&#46;4&#37; improved&#46; 83&#46;0&#37; of patients did not present with pre-operative campimetric defects&#58; 97&#46;7&#37; of those remained stable following the intervention and 2&#46;3&#37; experienced new campimetric defects following the surgery &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The grade of tumour resection &#40;total vs subtotal&#41; did not significantly influence the post-operative visual outcomes or visual acuity &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;71&#41;&#44; or campimetric impairment &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;53&#41;&#46; The location of the meningiomas did not significantly influence post-operative visual acuity either &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;67&#41;&#44; but with regard to campimetric impairment&#44; tuberculum sellae meningiomas experienced a significantly higher percentage of improvement over the other tumours &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Complications</span><p id="par0095" class="elsevierStylePara elsevierViewall">24&#46;5&#37; of patients presented with transient paresis of the third cranial nerve and 1&#46;9&#37;&#44; permanent &#40;3&#46;8&#37; of the patients presented with pre-operative paresis&#41;&#46; Infection was observed in 5&#46;7&#37; of surgical wounds&#44; requiring re-intervention in 2 out of 3 of patients for this reason&#46; The rate of post-operative cerebrospinal fluid fistulas was 3&#46;8&#37;&#44; with satisfactory resolution experienced with rest and external lumbar drainage&#44; with no re-intervention required for any patient&#46; No internal carotid injuries were reported&#46; The mortality rate was 0&#37;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The mean follow-up was 82&#46;3 months &#40;range 151&#8211;156&#41;&#46; 9&#46;4&#37; of patients required re-intervention&#58; 3&#46;8&#37; due to growth of tumour remnants and 5&#46;6&#37; due to tumour recurrence&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Anatomy</span><p id="par0105" class="elsevierStylePara elsevierViewall">The anterior clinoid process is a small&#44; conical process that projects from the posteromedial edge of the lesser wing of the sphenoid&#46; Its anatomy&#44; as well as its relationship with the adjacent structures&#44; has been described in detail in numerous articles&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">1&#44;9&#44;11&#44;12</span></a> Along with the orbital part of the frontal bone&#44; the clinoid process covers the orbital roof and lateral wall of the optic canal&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">1&#44;13</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">It is important to point out the role of the pre-operative CT to identify certain types of anatomical variants&#44; such as the carotico-clinoid foramen between the anterior and middle clinoid processes &#40;14&#8211;27&#37;&#41; or the interclinoid bony bridge between anterior and posterior clinoid processes &#40;3&#8211;9&#37;&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">1&#44;14</span></a> which would impose a limitation when performing a purely extradural clinoidectomy&#46; Additionally&#44; up to 30&#37; of patients in the series had pneumatisation of the clinoids&#44;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">14&#44;15</span></a> which should be taken into account to prevent incidental openings of the paranasal mucosa and its consequential complications &#40;rhinorrhoea&#44; mucocele&#44; pneumocephalus&#44; etc&#46;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">15</span></a> cerebrospinal fluid fistula may have been observed in more than 40&#37; of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a> Different scales to assess the pneumatisation of the clinoids have been described&#58; the most frequently used would be the proposal by Mikami et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">15</span></a> Type I&#58; posterior stem approach &#40;74&#37;&#41;&#59; Type II&#58; anterior stem approach &#40;15&#37;&#41;&#59; or Type III&#58; both &#40;11&#37;&#41;&#46; Another common scale&#44; but whose clinical application has been challenged would be the proposal by Abuzayed et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">17</span></a> Type I&#58; less than 50&#37; &#40;the most common&#41;&#59; Type II&#58; more than 50&#37;&#44; or Type III&#58; total&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Extradural vs intradural technique</span><p id="par0115" class="elsevierStylePara elsevierViewall">Despite the indisputable requirement for carrying out a resection of the anterior clinoids when addressing various skull base tumours&#44; the optimal surgical strategy has traditionally been a source of controversy&#46; Both the extradural and intradural approaches have their supporters and have been extensively discussed in the literature&#46; When comparing them&#44; we can say that the EAC is technically simpler and quicker&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a> and that it allows for a wider exposure and an earlier devascularisation of the tumour&#46; Additionally&#44; on conserving the dura mater as protection&#44; it is safer&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a> the need for intradural dissection is more limited<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">18</span></a> and the deposit of bone particles generated during reaming at the intradural level is avoided&#44; something that has been associated with post-operative headache&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">19</span></a> In those cases where the clinoids are pneumatised&#44; the rates of cerebrospinal fluid fistulas recorded in the literature following an EAC are fewer&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">10</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The advantages of intradural clinoidectomy would be the direct view of important intradural neurovascular structures and the possibility of adjusting the grade of extent of the clinoidectomy to individual needs&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">20&#8211;22</span></a> In the same way&#44; a concept introduced by Hernesniemi in 2011 is the adapted clinoidectomy&#44; with the capacity to adjust the grade of resection of the clinoids to the needs of each case&#46; While this technique is usually carried out intradurally&#44; it can also be carried out extradurally&#46; Accordingly&#44; we can differentiate between four grades of resection&#58; minimum &#40;less than 1&#47;3&#41;&#44; partial &#40;1&#47;3&#41;&#44; subtotal &#40;2&#47;3&#41; and total &#40;3&#47;3&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">23</span></a> Hybrid methods have also been described&#44; which try to combine the best of each technique&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">24</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Various authors have concluded that extradural clinoidectomy is superior to intradural clinoidectomy in most cases and can be used routinely for most supra- and parasellar injuries with minimal associated complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">10&#44;25&#44;26</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Approach&#44; indications and surgical technique</span><p id="par0130" class="elsevierStylePara elsevierViewall">EAC can be carried out via different approaches depending on the pathology to be treated&#44; the most prevalent in the literature being the pterional approach&#44; followed by the orbitozygomatic and lateral supraorbital approaches&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">23</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">We can currently identify two streams supporting routine clinoidectomy &#40;tuberculum sellae&#44; anterior clinoid process&#44; cavernous sinus or optic canal meningiomas&#41; and those that are conducted in selected cases<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">15&#44;23</span></a>&#58; when the tumour invades the optic canal or encompasses the internal carotid artery &#40;the objective would be to achieve good proximal control&#44; as well as safe vascular and optic nerve dissection&#41; or when there is prominent hyperostosis of the anterior clinoid process or the tumour is firmly attached to it &#40;with coagulation being insufficient to achieve a total tumour resection&#41;&#46; A study recently published in 2015 recommends its routine use&#44; claiming that up to 1&#47;4 of the patients in whom the clinoids appeared not to be invaded by the tumour&#44; tested positive in anatomical pathology for tumour cells&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a> Additionally&#44; in the event of a recurring tumour&#44; as the decompression of the optic nerve has already been performed&#44; theoretically the visual deterioration of the patient can be delayed&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">27</span></a> At our site&#44; we use routine EAC for those meningiomas located in the parasellar region&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Different methods have been described for carrying out bone resection&#44; each with its advantages and drawbacks&#44; from conventional reaming to more novel methods such as ultrasonic aspirators&#46; None of the techniques in the literature is superior to another&#46; Regarding reaming&#44; both indirect &#40;thermal&#41; and direct &#40;mechanical&#41; injuries have been observed in the adjacent neurovascular structures&#44; while continuous irrigation and the use of a diamond burr &#40;avoids injury to the paranasal sinus mucosa&#41; have been associated with a decrease in rates of associated complications&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">1</span></a> Ultrasonic bone aspirators&#44; having no rotating component&#44; are presented as a more stable and safer method<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">28</span></a>&#59; however&#44; this is a more expensive&#44; slower system with cases of intracranial nerve injury and spinal cord injury having been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">21&#44;29</span></a> Resections can also be conducted using a Kerrison rongeur<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">30</span></a> which involve a lower cost and shorter time&#44; but can cause compression injuries&#46; Lastly&#44; it is worth mentioning en bloc resection&#44; both intradurally<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">31</span></a> and extradurally&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">29</span></a> taking into account in this case the difficulty posed for accuracy of the direction of the fracture line&#46; At our site we use diamond burr under continuous irrigation&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Complications</span><p id="par0145" class="elsevierStylePara elsevierViewall">Among the complications associated with this technique we can highlight the following&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Optic nerve injury &#40;decrease in visual acuity&#44; campimetric defects&#41; &#40;0&#8211;13&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">3&#44;32&#44;33</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Third cranial nerve paresis<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">32&#44;33</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">1&#46;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Intradural clinoidectomy&#58; 10&#8211;75&#37; transient&#44; 4&#8211;13&#37; permanent&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">34</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">2&#46;</span><p id="par0165" class="elsevierStylePara elsevierViewall">EAC 8&#8211;14&#37; transient&#44; 0&#8211;5&#37; permanent&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a></p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">3&#46;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Internal carotid artery injury &#40;C5&#44; C6&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">3&#44;33</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">4&#46;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Pneumocephalus&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">3&#44;33</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">5&#46;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Aneurysm rupture &#40;when clinoidectomy is part of the approach&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">13&#44;27</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">6&#46;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Incidental opening of the paranasal sinuses &#40;above all&#44; the sphenoid sinus&#44; but also the ethmoid sinus&#41; 2&#46;7&#8211;7&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">3&#44;15&#44;23&#44;33</span></a></p></li></ul></p><p id="par0190" class="elsevierStylePara elsevierViewall">With regard to the opening of the paranasal sinuses&#44; the potential resulting complications are cerebrospinal fluid leakage&#44; pneumocephalus&#44; formation of mucocele and infection&#46; There are authors who support the routine use of fibrin glue<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>muscle<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>haemostatic patch &#40;Tachosil<span class="elsevierStyleSup">&#174;</span>&#41; to seal possible communications&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">23</span></a> However&#44; most girdle the intra-operative repair with different materials &#40;muscle&#44; fat&#44; oxycellulose&#44; fibrin glue&#44; etc&#46;&#41; in cases in which the communication is observed intra-operatively&#46; Some authors also consider cerebrospinal fluid fistula to be inevitable when the clinoids are pneumatised&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">3&#44;15</span></a> The treatment of the fistula can be conservative with rest&#44; or an external lumbar drain can be inserted&#44; or the patient can undergo surgical reintervention&#46; One technique described in 2006 &#40;M&#46; Lawton&#41; to repair the sphenoid sinus opening would be the so-called &#8220;yo-yo technique&#8221; which consists of inserting a temporal muscle fragment tied at its midpoint in the sphenoid sinus and subsequently withdrawing it to the subarachnoid space&#44; creating a plug &#40;the percentage of fistulas observed with this technique was 0&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Our series of patients with extradural anterior clinoidectomy</span><p id="par0195" class="elsevierStylePara elsevierViewall">Our results agree with the series previously published in the literature&#44; in which it has been described that the tumours of the anterior and middle fossa with proximity to the optic canal alter visual function before surgical intervention in 35&#8211;70&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">36&#44;37</span></a> Most of the studies recommend early EAC with decompression of the optic nerve to achieve better post-operative visual recuperation&#46; This recommendation is based mainly on the fact that the initial release of the optic nerve allows it to be managed more safely during the subsequent tumour resection&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">36&#8211;38</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Our main motivation for conducting EAC was impairment of the ACP by the meningioma and the compression of any part of the optical path&#44; whether it be the optic nerve or chiasm&#46; In the cases of impairment of the ACP&#44; we consider EAC to be very useful because in this way we achieve early devascularisation of the tumour and we remove the bone that is infiltrated by tumour on many occasions&#46; The EAC also allows for decompression and manipulation of the optic nerve in an initial phase of surgery&#44; opening the falciform ligament and it means the nerve can move with greater freedom&#44; reducing the possibility of it being injured during the tumour resection manoeuvres&#46; In cases in which the tumour has a prime location in the region of the tuberculum sellae&#44; with its consequential proximity to the chiasm and optic canal&#44; we believe that the decompression and early release of the optic nerve most affected by campimetry allows for its manipulation to avoid new injury during the removal of the meningioma&#46; We use the same reasoning for meningiomas that originate in the medial sphenoid wing or cavernous sinus&#44; and that come into contact with or are in the vicinity of the ipsilateral optic nerve&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Despite the advances in techniques and improvements in microsurgical material&#44; the incidence of post-operative visual deterioration&#44; although having improved with the passage of time&#44; still affects a considerable number of patients&#46; Post-operative results are defined by the extent of the resection as well as extent of the decompression of the optic nerve through the unroofing of the optic canal and anterior clinoidectomy&#46; Pre-operative visual state&#44; age&#44; duration and severity of visual symptoms&#44; presence of optic atrophy and the size of the tumour have been identified as prognostic factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">3&#44;16&#44;38</span></a> Sade and Lee found an important degree of correlation between the presence of hypertrophy of the anterior clinoid process and the occupation of the optic canal in meningiomas of the tuberculum sellae&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">39</span></a> In our series&#44; we did not find a statistically significant relationship between the grade of tumour resection and the post-operative visual outcomes&#46; However&#44; meningiomas of the tuberculum sellae experienced a post-operative percentage of improvement of campimetric impairments&#44; which was significantly higher than for the rest of the tumours &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">In our series&#44; 24&#46;5&#37; of patients presented with temporary paresis of the third cranial nerve and 1&#46;9&#37; had permanent paresis &#40;3&#46;8&#37; of the patients presented with pre-operative paresis&#41;&#44; although we consider again&#44; in agreement with the literature&#44; that this complication could be associated with the location and size of the tumour rather than the anterior clinoidectomy itself&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">25</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Based on the above&#44; and in our experience&#44; we believe that post-operative visual changes are related to pre-operative visual function and other prognostic factors cited above&#44; and that EAC would help to achieve a good post-operative visual outcome&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusions</span><p id="par0220" class="elsevierStylePara elsevierViewall">In our experience&#44; EAC is a safe technique that facilitates the resection of the meningiomas located in the parasellar area&#44; helps to achieve early tumour devascularisation&#44; reduces the need for retraction of the brain parenchyma and could play a positive role in the preservation of visual function and the appearance of tumour recurrences in the ACP&#46; There is no scientific evidence that various factors&#44; such as the opening of the superior orbital fissure&#44; the intradural pathway or the extradural pathway&#44; adapted clinoidectomy&#44; or the instruments used to carry out the bone resection affect the visual outcomes following anterior clinoidectomy&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0225" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1023133"
          "palabras" => array:4 [
            0 => "Parasellar meningiomas"
            1 => "Extradural anterior clinoidectomy"
            2 => "Visual outcomes"
            3 => "Anterior clinoid process"
          ]
        ]
      ]
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          "titulo" => "Palabras clave"
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          "palabras" => array:4 [
            0 => "Meningiomas paraselares"
            1 => "Clinoidectom&#237;a anterior extradural"
            2 => "Resultados visuales"
            3 => "Ap&#243;fisis clinoides anterior"
          ]
        ]
      ]
    ]
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The extradural anterior clinoidectomy &#40;EAC&#41; is a key microsurgical technique that facilitates the resection of tumours located in the parasellar region&#46; There is currently no consensus regarding the execution of the procedure via extradural or intradural nor scientific evidence that supports its routine use&#46; The purpose of this article is to expose our experience in performing EAC as part of the management of the parasellar meningiomas&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective analysis of the EAC for parasellar meningioma resection performed in our centre between 2003 and 2015 was done&#46; A total of 53 patients were recorded&#46; We analysed our series focusing on visual outcomes&#44; resection rates and complications&#46; Through an extensive bibliographic research&#44; we discussed the advantages and disadvantages of the EAC&#44; technical considerations&#44; comparison with the intradural clinoidectomy and its visual impact&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The most frequent tumours were anterior clinoidal meningiomas &#40;33&#46;9&#37;&#41;&#46; The most common initial symptoms were decreased visual acuity &#40;45&#46;3&#37;&#41; and headache &#40;22&#46;6&#37;&#41;&#46; A gross total resection was achieved in 67&#46;9&#37;&#44; being subtotal in the remaining 32&#46;1&#37;&#46; Regarding the visual deficits 67&#46;9&#37; of the patients presented clinical stability&#44; 22&#46;6&#37; improvement and 9&#46;4&#37; worsening&#46; The degree of tumour resection did not significantly influence post-surgical visual outcomes&#44; either visual acuity &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;71&#41; or campimetric alterations &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;53&#41;&#46; 24&#46;5&#37; of the patients experienced III nerve transient paresis and 1&#46;9&#37; permanent&#46; The postoperative cerebrospinal fluid leak rate was 3&#46;8&#37;&#46; Mortality rate was 0&#37;&#46; The mean follow-up was 82&#46;3 months&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In our experience&#44; EAC is a safe technique that facilitates the resection of the meningiomas located in the parasellar area&#44; helps to achieve early tumour devascularisation&#44; reduces the need for retraction of the cerebral parenchyma and could play a positive role in the preservation of visual function and the appearance of tumour recurrences in the anterior clinoid process &#40;ACP&#41;&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background and aim"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Materials and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La clinoidectom&#237;a anterior extradural &#40;CaE&#41; es una t&#233;cnica microquir&#250;rgica clave que facilita la resecci&#243;n de tumores localizados en la regi&#243;n paraselar&#46; Actualmente&#44; no existe consenso de la ejecuci&#243;n v&#237;a extradural o intradural&#44; o evidencia cient&#237;fica que apoye su uso de manera rutinaria&#46; El prop&#243;sito de este art&#237;culo es exponer nuestra experiencia en la realizaci&#243;n de la CaE como parte del manejo de los meningiomas paraselares&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un an&#225;lisis retrospectivo de las CaE empleadas en las resecciones de meningiomas paraselares realizadas en nuestro centro entre los a&#241;os 2003 y 2015&#46; Se registraron un total de 53 pacientes&#46; Realizamos un an&#225;lisis de nuestra serie de casos&#44; enfoc&#225;ndonos en los resultados visuales&#44; las tasas de resecci&#243;n y las complicaciones postoperatorias&#46; A trav&#233;s de una revisi&#243;n bibliogr&#225;fica&#44; se discuten las ventajas e inconvenientes de la CaE&#44; consideraciones t&#233;cnicas&#44; comparaci&#243;n con la clinoidectom&#237;a anterior intradural e impacto visual&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El tipo de tumor m&#225;s frecuente fueron los meningiomas de clinoides anterior &#40;33&#44;9&#37;&#41;&#46; Los s&#237;ntomas iniciales m&#225;s frecuentes fueron la disminuci&#243;n de la agudeza visual &#40;45&#44;3&#37;&#41; y la cefalea &#40;22&#44;6&#37;&#41;&#46; La resecci&#243;n tumoral total se consigui&#243; en el 67&#44;9&#37; de los casos&#44; siendo subtotal en el restante 32&#44;1&#37;&#46; Con respecto a los d&#233;ficits visuales&#44; el 67&#44;9&#37; de los pacientes presentaron estabilidad cl&#237;nica&#44; el 22&#44;6&#37; mejoraron y el 9&#44;4&#37; experimentaron empeoramiento&#46; El grado de resecci&#243;n tumoral no influy&#243; de manera significativa en los resultados visuales posquir&#250;rgicos&#44; ni en la agudeza visual &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;71&#41; ni en los d&#233;ficits campim&#233;tricos &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;53&#41;&#46; El 24&#44;5&#37; de los pacientes experimentaron paresia del III par transitoria y el 1&#44;9&#37;&#44; permanente&#46; La tasa de f&#237;stula de l&#237;quido cefalorraqu&#237;deo postoperatoria fue del 3&#44;8&#37;&#46; La mortalidad fue del 0&#37;&#46; El periodo medio de seguimiento fue de 82&#44;3 meses&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En nuestra experiencia&#44; la CaE es una t&#233;cnica segura que facilita la resecci&#243;n de los meningiomas localizados en la regi&#243;n paraselar&#44; favorece la desvascularizaci&#243;n temprana del tumor&#44; reduce la necesidad de retracci&#243;n del par&#233;nquima cerebral y podr&#237;a ejercer un papel positivo en la preservaci&#243;n de la funci&#243;n visual y en la aparici&#243;n de recidivas tumorales en la ap&#243;fisis clinoides anterior &#40;ACa&#41;&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0035"
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            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Salgado L&#243;pez L&#44; Mu&#241;oz Hern&#225;ndez F&#44; Asencio Cort&#233;s C&#44; Tresserras Rib&#243; P&#44; &#193;lvarez Holzapfel MJ&#44; Molet Teixid&#243; J&#46; Clinoidectom&#237;a anterior extradural en el manejo de meningiomas paraselares&#58; an&#225;lisis de 13 a&#241;os de experiencia y revisi&#243;n de la literatura&#46; Neurocirugia&#46; 2018&#59;29&#58;225&#8211;232&#46;</p>"
      ]
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        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; Pre-operative MRI where there is a tuberculum sellae meningioma involving the right optic nerve&#46; &#40;b&#41; Reconstruction of the pre-operative CT and &#40;c&#41; post-operative CT where the extent of the resection of the clinoid process and the orbital roof can be observed&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Initial symptomatology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Decreased visual acuity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;45&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Campimetric defects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;17&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Headache&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;22&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Exophthalmos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;17&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oculomotor nerve damage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;11&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Seizure crisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;15&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trigeminal nerve damage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hormone dysfunction&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Incident&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;3&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Initial symptomatology&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-operative visual acuity impairment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Stability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Improvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes&#58; 24 &#40;45&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;50&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;12&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;37&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-operative campimetric defects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Stability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Worsening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Improvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yes&#58; 9 &#40;17&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;44&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;11&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;44&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No&#58; 44 &#40;83&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43 &#40;97&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Visual outcomes&#46;</p>"
        ]
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:39 [
            0 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Surgical anatomy of the anterior clinoid process"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "P&#46; Huynh-Le"
                            1 => "Y&#46; Natatori"
                            2 => "T&#46; Sasaki"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jocn.2003.08.005"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Neurosci"
                        "fecha" => "2004"
                        "volumen" => "11"
                        "paginaInicial" => "283"
                        "paginaFinal" => "287"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14975418"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
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Article information

ISSN: 25298496
Original language: English

DOI:10.1016/j.neucie.2018.04.001

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