Dear all,
This is a 48 yr old lady presenting with long standing anosmia of 8 years and recent adult onset seizures. She has no deficits except bilateral anosmia. Attached is the contrast MRI.
Kindly advise regarding the approach to take out the tumour completely including that of the paranasal sinus part.
I am planning an extended subfrontal approach.
Will an endoscopic endonasal approach be required to mobilise the lower component?
Regards
Dr.Maqsood
Hi Maqsood
The sinus component looks very large and there also appears to be hypertelorism. Is it evident clinically?
Have you considered a transnasal biopsy of the tumor before definitive surgery? It might not be a meningioma at all and even if it is it might be atypical or malignant.
Approach wise -
Extended subfrontal should be able to remove the tumor completely, IMO. Needless to say, reconstruction of the ACF base will have to be meticulous.
All the best with this one. Do let us know how it goes.
Regards
Arvind
Dear Chief, i think the extended subfrontal approach should be enough for the lower part as well, in this case.
Dr. Anirban Deep Banerjee
Neurosurgeon( NIMHANS)
Dear Dr Maqsood,
Thank you for illustrating such a case. To me bi-frontal, or even unilateral sub-frontal approach may be enough for the intracranial part. It is a more or less olfactory groove meningioma invading the base. If you notice, there is no major edema around, denoting the presence of an arachnoid plain which will make your dissection a little easier. The endonasal part may be approached from above, being intra-tumoral all the time during dissection; or may be approached with a combined endo nasal approach. The absence of signal voids intratumorally is a good sign of safe dissection. The most important is the plan of reconstruction, to provide a good base reconstruct and to prevent fistula formation later on. Lastly, a good look at the hormonal profile of the patient is a mandatory pre- and post-operative task.
Looking forward to hear from you.
Thanks
Mohamed Mohi Eldin , MB-BCH , M.Sc., MD
Prof. of Neurosurgery, Faculty of Medicine, Cairo University, Egypt,
Dear maqsood,
Agree that extened transfrontal is ideal for excising tumor completely.
I disagree need for biopsy, regardless of path, and beingn or atypiacal or even nonmeningioma makes no difference for need for complete excision,
Would take a large pericranial graft going behind skin incision and keep duragen plus or eqvivlaent as standby.
you would be surprised at the extent of access from above once intraranial component is removed.
Bewre of retraction, use less or none as bothfrontal lobes are already edematous, give good amount of steroids perioperatively.
Best wishes
Le us know the outcome.
One of our members(not sure if he is in the group) will be salivating seeing this MRI as it is a good and challenging case to do entitely endoscopically by extended transnasal approach(he is our desi amin kassam!).
Satish
Dear Maqsood,
I would agree with Dr Satish that an extended subfrontal approach would suffice in this case. the approach is able to access lesions in the frontoethmoids and nasal cavities. it is only when the leson involves the maxillary sinuses (which is not the case here) that an additional nasal approach (median maxillectomy or an endoscopic approach ) may be needed. This looks like a meningioma (and hence a biopsy is really not required)and I feel the bifrontal approach also provides for an excellent (and a very important) repair of the base.
all the best
Ali
This is a 48 yr old lady presenting with long standing anosmia of 8 years and recent adult onset seizures. She has no deficits except bilateral anosmia. Attached is the contrast MRI.
Kindly advise regarding the approach to take out the tumour completely including that of the paranasal sinus part.
I am planning an extended subfrontal approach.
Will an endoscopic endonasal approach be required to mobilise the lower component?
Regards
Dr.Maqsood
Hi Maqsood
The sinus component looks very large and there also appears to be hypertelorism. Is it evident clinically?
Have you considered a transnasal biopsy of the tumor before definitive surgery? It might not be a meningioma at all and even if it is it might be atypical or malignant.
Approach wise -
Extended subfrontal should be able to remove the tumor completely, IMO. Needless to say, reconstruction of the ACF base will have to be meticulous.
All the best with this one. Do let us know how it goes.
Regards
Arvind
Dear Chief, i think the extended subfrontal approach should be enough for the lower part as well, in this case.
Dr. Anirban Deep Banerjee
Neurosurgeon( NIMHANS)
Dear Dr Maqsood,
Thank you for illustrating such a case. To me bi-frontal, or even unilateral sub-frontal approach may be enough for the intracranial part. It is a more or less olfactory groove meningioma invading the base. If you notice, there is no major edema around, denoting the presence of an arachnoid plain which will make your dissection a little easier. The endonasal part may be approached from above, being intra-tumoral all the time during dissection; or may be approached with a combined endo nasal approach. The absence of signal voids intratumorally is a good sign of safe dissection. The most important is the plan of reconstruction, to provide a good base reconstruct and to prevent fistula formation later on. Lastly, a good look at the hormonal profile of the patient is a mandatory pre- and post-operative task.
Looking forward to hear from you.
Thanks
Mohamed Mohi Eldin , MB-BCH , M.Sc., MD
Prof. of Neurosurgery, Faculty of Medicine, Cairo University, Egypt,
Dear maqsood,
Agree that extened transfrontal is ideal for excising tumor completely.
I disagree need for biopsy, regardless of path, and beingn or atypiacal or even nonmeningioma makes no difference for need for complete excision,
Would take a large pericranial graft going behind skin incision and keep duragen plus or eqvivlaent as standby.
you would be surprised at the extent of access from above once intraranial component is removed.
Bewre of retraction, use less or none as bothfrontal lobes are already edematous, give good amount of steroids perioperatively.
Best wishes
Le us know the outcome.
One of our members(not sure if he is in the group) will be salivating seeing this MRI as it is a good and challenging case to do entitely endoscopically by extended transnasal approach(he is our desi amin kassam!).
Satish
Dear Maqsood,
I would agree with Dr Satish that an extended subfrontal approach would suffice in this case. the approach is able to access lesions in the frontoethmoids and nasal cavities. it is only when the leson involves the maxillary sinuses (which is not the case here) that an additional nasal approach (median maxillectomy or an endoscopic approach ) may be needed. This looks like a meningioma (and hence a biopsy is really not required)and I feel the bifrontal approach also provides for an excellent (and a very important) repair of the base.
all the best
Ali
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