Combined Cranionasal Surgery for Spheno-Orbital Meningiomas Invading the Paranasal Sinuses, Pterygopalatine, and Infratemporal Fossa Moshe Attia 1 , Kunal S. Patel 1 , Jothy Kandasamy 1 , Philip E. Stieg 1 , Henry M. Spinelli 1,3 , Howard A. Riina 5 , Vijay K. Anand 2 , Theodore H. Schwartz 1,2,4 INTRODUCTION Spheno-orbital meningiomas (SOMs) comprise nearly 9% of all intracranial meningiomas (6, 33). First described by Cushing and Eisenhardt, SOMs grow in either as a discrete mass (“en masse”) or as a flat sheet (“en plaque”), associated with intraosseous tumor growth, hyperostosis, and soft tissue growth adherent to the dura (9, 17, 18, 36, 37). SOMs inevitably spread through the skull base. This growth can involve the greater and lesser sphenoid wing, orbit, periorbit, and middle fossa floor, as well as the anterior clinoid process, optic canal, superior orbital fissure, and ca- vernous sinus (CS) (17, 23, 32, 36, 37, 42, 44). Much less frequently, SOMs can invade the infratemporal fossa (ITF), the pter- ygopalatine fossa (PPF), and the paranasal sinuses, mainly the sphenoid and ethmoid sinus (reported 8%e12.5% in only few series) (3, 40, 44). Unmanaged expansion of the tumor can lead to proptosis and/or visual impairment by compression of the periorbit and the optic nerve (6, 23, 36, 37, 41, 44). The primary goal in the management of SOMs is radical resection by transcranial skull-base approaches with minimal morbidity (4, 17, 32, 40, 41, 44). However, a gross total resection (GTR) in these tumors is still challenging with less than 40% rate reported in some series (23, 33, 36, 37) and the use of repeated surgery and adjuvant radiation therapy are often required (23,35e37, 42, 44). Extracranial invasion of the ITF, PPF, and the paranasal sinuses not only renders complete resection of SOMs more difficult through a transcranial approach but increases the risk of postoperative cerebro- spinal fluid (CSF) leak when the sinuses are breached from above. Endoscopic endonasal skull-base ap- proaches have evolved in the recent years to afford a minimal access but maximally aggressive technique to aid in the resection of skull-base tumors and meningiomas in precisely these extracranial compartments (8, 10e16, 19, 26, 28, 31, 43, 47e49). The natural corridors of the endonasal approaches are the paranasal sinuses, such as the sphe- noid, ethmoid, and maxillary sinuses, that facilitate the transsphenoidal (7, 43), trans- ethmoidal (19, 43), and transpterygoid (22, 25, 43) approaches, respectively. The concept of a combined “cranionasal” approach (i.e., - OBJECTIVE: To evaluate the efficacy of combining an endonasal endoscopic skull-base approach and repair with a transcranial orbitozygomatic approach for spheno-orbital meningiomas (SOMs). - METHODS: Three patients with recurrent SOMs underwent combined orbi- tozygomatic and endonasal endoscopic surgery. In 2 patients both procedures were done in 1 operation and in 1 patient the endonasal surgery was done 2.5 months after the craniotomy. Extent of resection, complications, morbidity, and mortality were evaluated. - RESULTS: Gross total resection was achieved in 1 patient and near total resection in the other 2 patients with tumor left in the cavernous sinus and parapharyngeal space. Two patients suffered cranial neuropathy from the transcranial surgery and the other developed a pseudomeningocele. There were no complications from the endonasal surgery. Patients having combined single setting cranionasal surgery were discharged on day 6 and 8, whereas the patient having only the endonasal component on a later date was discharged on day 2. - CONCLUSIONS: A combined cranionasal approach involving transcranial orbitozygomatic and endonasal endoscopic approaches is an effective 2-stage surgery for resecting SOMs invading into the sinuses and paranasal compart- ments. The ability to perform a multilayer closure involving a vascularized nasoseptal flap additionally decreases the risk of postoperative cerebrospinal fluid leak. Key words - Endoscopic endonasal - Infratemporal fossa - Paranasal sinuses - Pterygopalatine fossa - Skull base - Spheno-orbital meningioma - Transpterygoid approach - Transsphenoidal approach Abbreviations and Acronyms CS: Cavernous sinus CSF: Cerebrospinal fluid GTR: Gross total resection ICA: Internal carotid artery ITF: Infratemporal fossa MRI: Magnetic resonance imaging PPF: Pterygopalatine fossa SOM: Spheno-orbital meningioma STR: Subtotal resection From the Departments of 1 Neurosurgery, 2 Otolaryngology, 3 Plastic and Reconstructive Surgery, and 4 Neurology and Neuroscience, Weill Cornell Medical College, New York Presbyterian Hospital, New York; and 5 Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA To whom correspondence should be addressed: Theodore H. Schwartz, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2013) 80, 6:e367-e373. http://dx.doi.org/10.1016/j.wneu.2012.10.016 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2013 Elsevier Inc. All rights reserved. WORLD NEUROSURGERY 80 [6]: e367-e373, DECEMBER 2013 www.WORLDNEUROSURGERY.org e367 Peer-Review Short Reports
Transcript
Peer-Review Short Reports
Combined Cranionasal Surgery for Spheno-Orbital Meningiomas Invading the Paranasal
Sinuses, Pterygopalatine, and Infratemporal Fossa
Moshe Attia1, Kunal S. Patel1, Jothy Kandasamy1, Philip E. Stieg1, Henry M. Spinelli1,3, Howard A. Riina5,
Vijay K. Anand2, Theodore H. Schwartz1,2,4
-OBJECTIVE: To evaluate the efficacy of combining an endonasal endoscopicskull-base approach and repair with a transcranial orbitozygomatic approach forspheno-orbital meningiomas (SOMs).
-METHODS: Three patients with recurrent SOMs underwent combined orbi-tozygomatic and endonasal endoscopic surgery. In 2 patients both procedureswere done in 1 operation and in 1 patient the endonasal surgery was done 2.5months after the craniotomy. Extent of resection, complications, morbidity, andmortality were evaluated.
-RESULTS: Gross total resection was achieved in 1 patient and near totalresection in the other 2 patients with tumor left in the cavernous sinus andparapharyngeal space. Two patients suffered cranial neuropathy from thetranscranial surgery and the other developed a pseudomeningocele. There wereno complications from the endonasal surgery. Patients having combined singlesetting cranionasal surgery were discharged on day 6 and 8, whereas the patienthaving only the endonasal component on a later date was discharged on day 2.
-CONCLUSIONS: A combined cranionasal approach involving transcranialorbitozygomatic and endonasal endoscopic approaches is an effective 2-stagesurgery for resecting SOMs invading into the sinuses and paranasal compart-ments. The ability to perform a multilayer closure involving a vascularizednasoseptal flap additionally decreases the risk of postoperative cerebrospinalfluid leak.
Abbreviations and AcronymsCS: Cavernous sinusCSF: Cerebrospinal fluidGTR: Gross total resectionICA: Internal carotid arteryITF: Infratemporal fossaMRI: Magnetic resonance imagingPPF: Pterygopalatine fossaSOM: Spheno-orbital meningiomaSTR: Subtotal resection
From the Departments of 1Neurosurgery,2Otolaryngology, 3Plastic and Reconstructive
Surgery, and 4Neurology and Neuroscience, Weill CornellMedical College, New York Presbyterian Hospital, New York;and 5Department of Neurosurgery, New York UniversityLangone Medical Center, New York, New York, USA
To whom correspondence should be addressed:Theodore H. Schwartz, M.D.[E-mail: [email protected]]
Citation: World Neurosurg. (2013) 80, 6:e367-e373.http://dx.doi.org/10.1016/j.wneu.2012.10.016
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2013 Elsevier Inc.
INTRODUCTION
Spheno-orbital meningiomas (SOMs)comprise nearly 9% of all intracranialmeningiomas (6, 33). First described byCushing and Eisenhardt, SOMs grow ineither as a discrete mass (“en masse”) or asa flat sheet (“en plaque”), associated withintraosseous tumor growth, hyperostosis,and soft tissue growth adherent to the dura(9, 17, 18, 36, 37). SOMs inevitably spreadthrough the skull base. This growth caninvolve the greater and lesser sphenoidwing, orbit, periorbit, and middle fossafloor, as well as the anterior clinoid process,
All rights reserved.
WORLD NEUROSURGERY 80 [6]: e367-e3
optic canal, superior orbital fissure, and ca-vernous sinus (CS) (17, 23, 32, 36, 37, 42, 44).Much less frequently, SOMs can invadethe infratemporal fossa (ITF), the pter-ygopalatine fossa (PPF), and the paranasalsinuses, mainly the sphenoid and ethmoidsinus (reported 8%e12.5% in only fewseries) (3, 40, 44). Unmanaged expansion ofthe tumor can lead to proptosis and/or visualimpairment by compression of the periorbitand the optic nerve (6, 23, 36, 37, 41, 44).The primary goal in the management of
SOMs is radical resection by transcranialskull-base approaches with minimalmorbidity (4, 17, 32, 40, 41, 44). However,a gross total resection (GTR) in thesetumors is still challenging with less than40% rate reported in some series (23, 33,36, 37) and the use of repeated surgery andadjuvant radiation therapy are oftenrequired (23,35e37, 42, 44).
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Extracranial invasion of the ITF, PPF,and the paranasal sinuses not onlyrenders complete resection of SOMs moredifficult through a transcranial approach butincreases the risk of postoperative cerebro-spinal fluid (CSF) leak when the sinuses arebreached from above.Endoscopic endonasal skull-base ap-
proaches have evolved in the recent years toafford a minimal access but maximallyaggressive technique to aid in the resection ofskull-base tumors and meningiomas inprecisely these extracranial compartments(8, 10e16, 19, 26, 28, 31, 43, 47e49). Thenatural corridors of theendonasal approachesare the paranasal sinuses, such as the sphe-noid, ethmoid, and maxillary sinuses, thatfacilitate the transsphenoidal (7, 43), trans-ethmoidal (19, 43), and transpterygoid (22, 25,43) approaches, respectively. The concept ofa combined “cranionasal” approach (i.e.,
a transcranial approach combined with anendonasal endoscopic approach for multi-compartmental tumors) has been usedprimarily for malignant anterior skull-basetumors, such as esthesioneuroblastomas,that invade through the cribriform plate (21,38, 46). The combination of lateral trans-cranial skull-base approaches with a lateral(transpterygoidal) endonasal skull-baseapproach for SOMs has not been reported todate. In this article we report on 3 consecutivepatients with SOMs invading into either theparanasal sinuses, the PPF, or the ITF, inwhich an endonasal skull-base approach wasused to reach theparanasal sinusaspect of thetumor,whichwouldbemost difficult to reachfrom above, in combination with a trans-cranial approach to remove the bulk of thetumor from above. In addition, a vascularizednasoseptalflapwas harvested fromwithin thesinuses and used to minimize the risk ofpostoperative CSF leak. The technical detailsand nuances, as well as the patients’ resultsand outcomes are discussed.
Figure 1. Preoperative and postoperative magnetic resonance imaging (MRI) of patient 2 (Table 1).(A) Preoperative axial MRI with contrast demonstrating the spheno-orbital meningioma (T) invadingthe sphenoid sinus (SS) through the lateral wall (arrow). (B) Preoperative coronal MRI with contrastdemonstrating the spheno-orbital meningioma (T) invading (arrow) the infratemporal fossa (ITF)through the middle fossa floor and the sphenoid sinus (SS) through the lateral wall. (C) Postoperativeaxial MRI without contrast demonstrates no tumor in the sphenoid ridge region as well as in thesphenoid sinus (SS). (D) Postoperative axial MRI with contrast demonstrates absence of tumor.
MATERIALS AND METHODS
Patient PopulationFrom December 2009 to September 2011, 3consecutive patients were operated on usingcombined transcranial and endonasalapproaches for SOMs involving the sphenoidwing, orbit,middle fossafloor, ITF, PPF, andparanasal sinuses. Two patients underwentboth surgeries consecutively in 1 operation,whereas 1 patient underwent the endonasalsurgery 2.5monthsafter the craniotomy.All 3patients had been previously operated onthrough a craniotomy and presented withtumor recurrence; 2 of the patients havingundergone prior radiation therapy, onefractionated and the other single dose radi-osurgery (Table 1).The Weill Cornell Medical CollegeeNew
York Presbyterian Hospital InstitutionalReview Board approved this study.
Clinical and Radiologic EvaluationMedical records were retrospectively re-viewed for medical history, physical exami-nation, neurologic status, visual function,imaging studies, operative reports, surgicaltechnique, surgical outcomes, hospitaliza-tion, and follow-up. The diagnosiswasmadeby magnetic resonance imaging (MRI) andhistology. After surgery, all patients had anMRI scan with contrast at follow-up to
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determine the extent of resection andrecurrence of tumor. The MRI reading wasdone by a neuroradiologist. Details are pre-sented in Table 1.
Evaluation of Visual FunctionTwo of the patients in the present studyunderwent formal visual field testingbefore and after operation by a neuro-ophthalmologist, which included Hum-phrey perimetry and visual acuity. Onepatient had only a preoperative evaluation.
Surgical TechniqueTranscranial Approach. All 3 patients wereoperated on using the frontotemporalcraniotomy and orbitozygomatic osteotomy,which has been well described elsewhere(1, 2, 5, 27, 29, 50). The intracranial, orbital,periorbital, subtemporal, ITF, and PPFportion of the SOM was removed ascompletely as possible with the aid of theoperating microscope and microsurgicaltechniques (23, 36, 37, 41, 44). At the end ofthe surgery, the plastic and reconstructive
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surgeons reconstructed the calvarium, orbit,and the skull base from above. In 1 patient,a preoperative cerebral angiogram andballoon occlusion test was performed on theinternal carotid artery (ICA) on the side ofthe tumor that allowed sacrificing this ICAduring surgery before the tumor was resec-ted from the CS. In another patient a preop-erative cerebral angiogram and tumorembolization was carried out 1 day beforesurgery.
Endoscopic Endonasal Approach. One patientwas operated on using the transsphenoidaltransethmoidal approach to the SOMcomponent invading the sphenoid sinusthrough the lateral wall, and 2 patientswere operated on through the combinedtranssphenoidal, transethmoidal, trans-maxillary, and transpterygoid approachesto a sphenoid sinus meningioma in 1 caseand to a sphenoid and ethmoid sinusmeningioma in the second case. In these 2patients, part of the ITF and PPF compo-nent of the meningioma that was left after
Figure 2. Intraoperative photographs using a 30-degree endoscope during the endoscopic endonasalapproach. (A) Intraoperative photograph (patient 3) demonstrating the spheno-orbital meningioma (T)invading the sphenoid sinus (SS) through the lateral wall (arrow). ST, sella turcica; PS, planumsphenoidale. (B) Intraoperative photograph (patient 1) demonstrating the spheno-orbital meningioma(T) invading the sphenoid sinus (SS) through the lateral wall (arrow) and a component extending fromthe pterygopalatine fossa (PPF) (arrow). (C) Intraoperative photograph showing the vascularizednasoseptal flap (arrow) reconstructing the defect in the lateral wall of the sphenoid sinus after tumorresection (patient 3). (D) Intraoperative photograph (patient 3) showing DuraSeal (Covidien,Mansfield, Massachusetts, USA) sealant (arrow) over the nasoseptal flap (arrow) to keep it in place.
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MOSHE ATTIA ET AL. COMBINED CRANIONASAL SURGERY
the resection with the craniotomy, was alsoresected through the endoscopic endonasalapproach.The details of the expanded endoscopic
endonasal transsphenoidal (7, 19, 24, 43)and transpterygoid (22, 25, 43) approacheshave been previously described in detail inthe literature.The patient’s head was placed in a three-
pin Mayfield head-holder in a 15-degreerotation to the right and slightly extended.When the transcranial approach was per-formed before the endoscopic endonasalapproach at the same sitting, the operatingroom table was rotated to the right to reachthe appropriate angle.Under endoscopic visualization at
0 degree, with an 18-cm long, 4-mm diam-eter rigid endoscope (Karl Storz, Tuttlingen,Germany), the middle and superior turbi-nates were retracted laterally, and the sphe-noid ostia were identified bilaterally. Avascularized nasoseptal flap was harvestedand kept at the nasopharynx (20).
The Transsphenoidal TransethmoidalApproach. Using the transsphenoidal trans-ethmoidal approach (43), the posterior 1 cmof the nasal septum adjacent to the vomerand maxillary crest was resected. The sphe-noid ostia were opened with Kerrison ron-geurs (Codman/Johnson & Johnson,Raynham, Massachusetts, USA) anda complete sphenoidotomy was achieved.The mucosa of the sphenoid sinus wasremoved and the rostrum drilled flush withthe floor of the sphenoid sinus using anXMaxpneumatic drill (Anspach, PalmBeachGardens, Florida, USA). The intersinussphenoid septum was removed using thedrill and a rongeur forceps. The posteriorwall and the lateral walls of the sphenoidsinus and tumor extending into these areaswere thus brought into full view usingstraight and angled endoscopes.The transethmoidal corridor was opened
using a total anterior and posterior eth-moidectomy by performing an uncinec-tomy and opening of the ethmoid bullawitha tissue shaver. This provided exposure totumor eroding into the ethmoid sinuses.
The Transmaxillary Transpterygoid Approach.Using the transmaxillary transpterygoidapproach (43), a complete ethmoidectomyand sphenoidotomy was achieved. Themaxillary sinus ostium was widened afteruncinectomy. The sphenoid sinus was
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entered through a medial and inferiortransethmoidal approach and was widelyenlarged, allowing the access to the lateralwall of the sphenoid sinus and the ITF. Theposterior maxillary sinus mucosa waselevated off the orbital process of the pala-tine bone and from the posterior wall of themaxillary sinus. Removal of the poster-omedial wall and the posterior wall of themaxillary sinus exposed the PPF and the ITF,respectively. The crista ethmoidalis and themedial pterygoid plate were removed toexpose the region covered by the lateral wallof the sphenoid sinus. Removal of this bonereveals the medial wall of the CS as well asthe second (V2) and third (V3) divisions ofthe trigeminal nerve and the vidian nerve,which is often used as a landmark to identifythe petrous ICA.After the tumor was identified, it was
dissected and resected from the paranasalsinuses, as well as from the ITF and PPF,using microsurgical techniques.
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Skull Base ReconstructionSkull base reconstruction generally con-sisted of a multilayer closure that includeda fat graft covered with a vascularizednasoseptal flap (20) and layer of DuraSeal(Covidien, Mansfield, Massachusetts,USA) to hold the flap in place and thenFloseal (Baxter, Deerfield, Illinois, USA).In 1 patient with no obvious intraoperativeCSF leak, only Floseal was used.
RESULTS
Two patients were operated on at the samesitting (patients 2 and 3). In one of thema GTR was achieved (Figure 1). In thesecond, a subtotal resection (STR) wasachieved with residual tumor left in the CStreated with hypofractionated radio-therapy. One patient (#1) was operated firstthrough transcranial approach and 2.5months later in a second stage, through theendoscopic endonasal approach. An STR
Mariniello et al., 2008 (32) 60 66.7% 50.0% 9.7 years 42.3% 3.3%
NA, not available.
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MOSHE ATTIA ET AL. COMBINED CRANIONASAL SURGERY
was achieved with a residual tumor left inthe parapharyngeal space and orbital apex.The ITF and the sphenoid sinus were
invaded by the tumor in all patients; thePPF was invaded in 2 patients and theethmoid sinus was invaded in 1 patient(Table 1). In all 3 patients the ITF and in2 patients the PPF were invaded throughthe middle fossa floor (Figure 1B) and thesphenoid sinus was invaded through thelateral wall (Figures 1A, B and 2A, B).Postoperative CSF lumbar drainage was
carried out in 2 patients at a rate of 5 mL/hour for 3 days. There were no post-operative CSF leaks in all of our patients.The 2 patients having a craniotomy and anendonasal procedure in the same sittingwere discharged on postoperative days 8
Table 3. Rates of Spheno-Orbital MeningiomaPterygopalatine Fossa, and Paranasal Sinuse
Authors
Paranasal S
SphenoidSinus
E
Shrivastava et al., 2005 (44) 4% (1/25)8%
4(2
Sandalcioglu et al., 2005 (40) NA
Bloss et al., 2010 (3) 11.4% (5/44)*
*The percentage of invasion into the sphenoid sinus refers to thepatients with spheno-orbital meningiomas.
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and 6. The patient having only an endo-nasal procedure was discharged on post-operative day 2.There was no mortality in this study.
Morbidity resulting from the transcranialprocedure is listed in Table 1. There was nomorbidity from the endonasal procedure.
DISCUSSION
SOMs present a complex and challengingsurgical condition. Although most of thesetumors are slow growing, the involvementand invasion of the skull base and orbitleads to proptosis, visual impairments, andcranial nerve dysfunction due to involve-ment of the periorbit, optic canal, superiororbital fissure, and CS (36, 37, 39, 41, 44).
s Invading the Infratemporal Fossa,s
inuses
InfratemporalFossa
PterygopalatineFossa
thmoidSinus
% (1/25)/25)
8% (2/25) NA
NA NA 12.5% (2/16)
NA NA NA
whole series of sphenoid wing meningiomas that included
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The development of various skull-baseapproaches, such as frontotemporal crani-otomies with additional osteotomies in-cluding bony orbital and/or zygomaticsegments, has encouraged more radicalresection of SOMs. Although GTR can beachieved through these transcranial skull-base approaches at 66.7%e90% of the time(17, 32, 40, 41, 44), some recent reportsdemonstrate a less than 40%Simpson gradeI or II resection (23, 33, 36, 37, 45). In addi-tion, relatively high recurrence rates(17.9%e56.3%) have been reported inseveral series (Table 2) (23, 32, 36, 37, 40).Although surgery remains the primary
treatment modality, current treatmentparadigms must anticipate residual tumorafter incomplete SOM resection, particu-larly in the CS and superior orbital fissure(3, 36, 37, 41, 44). Although there isa paucity of literature on the subject, SOMsinvade the ITF, the PPF, and the paranasalsinuses roughly 8%e12% of the time(Table 3) (3, 40, 44). Given the multi-compartmental nature of these tumors,higher rates of GTR may require combinedapproaches. Even if GTR cannot be ach-ieved, reducing the size of residual tumorburden is advantageous in planning anddosing efficacious adjuvant radiotherapy(6, 23, 36, 37, 41, 44).Although it is possible to try and
remove the nasal and paranasal tumorthrough a single craniotomy (3, 40, 44), analternate strategy we have adopted is to
combine the orbitozygomatic approachwith an endonasal endoscopic approach,each of which has strengths to comple-ment the other approach. This strategyis similar to the combined cranionasalapproach that has been advocated formalignant neoplasms of the anterior skullbase (21, 38, 46) but extends the paradigmto a new location. These 2 surgeries can-either be performed during the sameoperation or on 2 separate dates. Endo-scopic endonasal surgery offers a directventral route to the sphenoid and ethmoidsinuses and paranasal anterior skull basethat does not require brain retraction and/or manipulation of neurovascular structuresen route to the pathology, as might berequired using a uniquely transcranialapproach (8, 10e16, 19, 26, 28, 31, 43,47e49). In addition, with the transpterygoidapproach (22, 25, 43), surgeons can accesstumors in the ITF and the PPF, whichprovided us with the ability to resect thoseareas of the SOM that are more difficult toaccess transcranially. In following theguiding principles of meningioma surgery,the only definitive cure for meningiomas iscomplete surgical resection. The morecomplete the resection is achieved, the lesschance of recurrence (3, 4, 34, 45). In thisstudy we achieved acceptable extent ofresection; GTR in 1 case and near total STRin 2 patients with a residual tumor in the CSin one and in the nasopharyngeal space andorbital apex in the second patient. All of thepatients are doing well with GlasgowOutcome Score of 5, except for persistentpostoperative cranial nerve deficits related tothe craniotomy, which is the most commonpostoperative complication described afterSOM surgery (23, 32, 35e37, 40, 44), and 1patient lost vision in his left eye, mostprobably due to surgical manipulation oftumor encasing and severely adherent to theoptic nerve. Likewise, we believe that theaddition of a vascularized nasoseptal flap tothe skull-base closure will decrease the riskof CSF leak after aggressive surgical resec-tion (20, 30).
CONCLUSIONS
Endoscopic endonasal surgery is a usefuladjunct that complements a lateral trans-cranial skull-base approach for SOMsinvading into theparanasal sinuses, ITF, andPPF. The combination of the 2 procedures,either in 1 or 2 operations is both safe and
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feasible. This paradigm, which takesadvantage of the strengths of each proce-dure, requires careful patient selection andmay be used in other anterior and lateralskull base meningiomas and neoplasms.
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Conflict of interest statement: The authors declare that thearticle content was composed in the absence of anycommercial or financial relationships that could be construedas a potential conflict of interest.
Received 7 March 2012; accepted 9 October 2012;published online 13 October 2012
Citation: World Neurosurg. (2013) 80, 6:e367-e373.http://dx.doi.org/10.1016/j.wneu.2012.10.016
Journal homepage: www.WORLDNEUROSURGERY.org
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