UNASSIGNED: Growth hormone (GH)--secreting pituitary adenomas can be aggressive and difficult to manage. Surgical resection for GH-secreting tumors remains the gold standard with increasing use of expanded endoscopic endonasal (EEA) techniques. Certain anatomical considerations make postsurgical biochemical remission challenging.
UNASSIGNED: We describe the case of a 43-year-old male presenting with acromegaly after a lack of biochemical remission from a previous surgery. Resection of the residual tumor invading the retrogenu compartment of the cavernous sinus was challenging for several reasons: (a) its location adjacent to the right parasellar horizontal internal carotid artery (ICA) with involvement of the medial wall, (b) the large kissing bilateral ICAs reducing the intercarotid distance, and (c) potential scar tissue. EEA was undertaken with key surgical steps, including wide bilateral sphenoidotomies, right middle clinoidectomy to access the clinoidal ICA and the retrogenu compartment, identification of the top of the paraclival ICA by drilling across the sella floor, division of the sellar floor dura to increase the intercarotid distance and transcavernous mobilization of medial wall, and the tumor capsule away from the horizontal parasellar ICA and across to the diaphragm and pituitary gland. Postoperatively, biochemical remission was achieved with no new endocrine deficits.
UNASSIGNED: These surgical nuances permit biochemical remission in complex revisional cases with acromegaly.

BACKGROUND: The endoscopic endonasal transsphenoidal approach (EETA) has revolutionized skull-base surgery; however, it is associated with a steep learning curve (LC), necessitating additional attention from surgeons to ensure patient safety and surgical efficacy. The current literature is constrained by the small sample sizes of studies and their observational nature. This systematic review aims to evaluate the literature and identify strengths and weaknesses related to the assessment of EETA-LC.
METHODS: A systematic review was conducted following the PRISMA guidelines. PubMed and Google Scholar were searched for clinical studies on EETA-LC using detailed search strategies, including pertinent keywords and Medical Subject Headings. The selection criteria included studies comparing the outcomes of skull-base surgeries involving pure EETA in the early and late stages of surgeons\' experience, studies that assessed the learning curve of at least one surgical parameter, and articles published in English.
RESULTS: The systematic review identified 34 studies encompassing 5,648 patients published between 2002 and 2022, focusing on the EETA learning curve. Most studies were retrospective cohort designs (88%). Various patient assortment methods were noted, including group-based and case-based analyses. Statistical analyses included descriptive and comparative methods, along with regression analyses and curve modeling techniques. Pituitary adenoma (PA) being the most studied pathology (82%). Among the evaluated variables, improvements in outcomes across variables like EC, OT, postoperative CSF leak, and GTR. Overcoming the initial EETA learning curve was associated with sustained outcome improvements, with a median estimated case requirement of 32, ranging from 9 to 120 cases. These findings underscore the complexity of EETA-LC assessment and the importance of sustained outcome improvement as a marker of proficiency.
CONCLUSIONS: The review highlights the complexity of assessing the learning curve in EETA and underscores the need for standardized reporting and prospective studies to enhance the reliability of findings and guide clinical practice effectively.

UNASSIGNED: Giant internal carotid artery (ICA) aneurysms are usually treated through flow diversion, coiling, or a combination of both. However, certain cases that fail the endovascular treatment pose a technical challenge.
UNASSIGNED: A 68-year-old male presented with gradual visual changes affecting his right eye and was found to have a giant unruptured right paraophthalmic aneurysm. The aneurysm showed growth, and the patient\'s symptoms worsened despite coiling and flow diversion. Due to the location of this aneurysm and persistent compression of the optic chiasm by the coil mass, his right ICA was sacrificed, and an expanded endoscopic endonasal approach was successfully used to clip the residual aneurysm, remove the coil mass, and thus, decompress the optic chiasm. The patient\'s visual symptoms improved after that, and post clipping imaging demonstrated adequate occlusion of his right paraophthalmic aneurysm.
UNASSIGNED: Recognizing the option of an endoscopic endonasal approach for clipping giant internal carotid aneurysms is of great importance. This approach can be safe and technically successful for the treatment of paraophthalmic aneurysms that fail the typical endovascular treatment.

Odontoid pannus is an abnormal collection of degenerative or inflammatory tissue on the C1-dens joint that can result in severe spinal cord compression myelopathy. Treatment options vary depending on severity and etiology. In cases of severe cord compression, surgical management could be either through a purely posterior approach or in combination with an anterior decompression via endoscopic endonasal approach (EEA). This case presents a 77-year-old female who underwent posterior cervical fixation for odontoid pannus causing dramatic cervical myelopathy who failed to improve over a 6-month period and required anterior transodontoid pannus resection and decompression via EEA. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23176.

Originally pioneered in adults, endoscopic endonasal approaches for skull base pathology are being increasingly applied as a minimally invasive alternative for young children. Intrinsic anatomic differences between these patient populations have sparked discussions on the feasibility, safety, and efficacy of these techniques in pediatric patients. This work aims to serve as a primer for clinicians engaged in the rapidly evolving field of pediatric endoscopic skull base surgery. A succinct overview of relevant embryology, sinonasal anatomy, and diagnostic workup is presented to emphasize key differences and unique technical considerations. Additional discussions regarding select skull base lesions, reconstructive paradigms, potential surgical complications, and postoperative care are also highlighted in the setting of multidisciplinary teams.

This systematic review aims to characterize ongoing clinical trials and therapeutic treatment options for chordoma, a rare notochordal remnant tumor that primarily affects the cranial base, mobile spine, and sacrum. While radical surgical resection remains the cornerstone for chordoma management, unique technical challenges posed by its proximity to critical neurovascular structures confer a tendency towards disease recurrence which often requires additional treatment modalities. In an attempt to better understand the current treatment landscape, a systematic review was designed to identify clinical trials directed at chordoma. A total of 108 chordoma trials were identified from four clinical trial databases; fifty-one trials were included in the final analysis, of which only 14 were designated as completed (27.5%). Aggregate data suggests most chordoma interventions are repurposed from other neoplasms that share common molecular pathways, with a recent emphasis on combination therapeutics within and across drug classes. Naturally, the publication and dissemination of clinical trial results remain a concern (n = 4, 28.6%), highlighting the need for enhanced reporting and transparency measures. Active clinical trial efforts are quite promising, with a renewed focus on novel biotherapeutic targets and deciphering the natural history, as well as survivorship of this complex disease.

Objectives  Preoperative planning of endoscopic skull base surgery (ESBS) is essential. The safety of performing surgery before managing sinus pathologies including concurrent chronic rhinosinusitis (CRS) in patients undergoing ESBS has been questioned. The current study aimed to evaluate and compare the complication rates between patients with and without CRS undergoing ESBS. Design  This is a retrospective study. Setting  Present study was conducted at tertiary referral center. Participants  We included all patients who underwent ESBS between March 2015 and March 2021. However, patients who had surgical revision for remnant tumor, primary sinonasal tumor excision, and cerebrospinal fluid (CSF) leakage repair were excluded. The presence of concurrent CRS was determined according to the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS 2020) criteria by reviewing electronic charts about the preoperative clinical assessment and CT scan images of the paranasal sinuses. Then, the incidence rates of postoperative meningitis, CSF leakage, and surgical site infection were compared between patients with and without concurrent CRS undergoing ESBS. Main Outcome Measures  Postoperative complication rates in patients underwent ESBS with and without CRS. Results  From a total of 130 ESBS cases, 99 patients were included in this study. Among them, 24 had concurrent CRS. One patient presented with postoperative meningitis, one with CSF leakage, and two with surgical site infections. The incidence rate of postoperative meningitis, CSF leakage, and surgical site infection did not significantly differ between patients with and without concurrent CRS. Conclusion  Concurrent CRS is not a contraindication for ESBS. Moreover, simultaneous endoscopic sinus surgery can safely be performed without additional morbidity in ESBS.

OBJECTIVE: Spheno-orbital meningiomas are rare tumors, accounting for up to 9% of all intracranial meningiomas. Patients commonly present with proptosis, and visual deficits. These slow growing tumors are hard to resect due to extension into several anatomical compartments, resulting in recurrence rates as high as 35-50%. Although open surgical approaches have been historically used for resection, a handful of endoscopic approaches have been reported in recent years. We aimed to review the literature and describe a case of spheno-orbital meningioma with severe vision loss which was resected with an endoscopic endonasal approach achieving complete resolution of visual symptoms.
METHODS: A systematic review of literature was conducted in accordance with the PRISMA guidelines. PubMed, Cochrane, and Web of Science databases were queried for spheno-orbital meningiomas resected via an endoscopic endonasal approach. Furthermore, the presentation, surgical management, and post-operative outcomes of a 53-year-old female with a recurrent spheno-orbital meningioma are described.
RESULTS: The search yielded 26 articles, of which 8 were included, yielding 19 cases. Average age at presentation was 60.5 years (range: 44-82), and 68.4% of patients were female. More than half of the cases achieved subtotal resection. Common complications associated with endoscopic endonasal surgery included CN V2 or CN V2/V3 hypoesthesia. Following surgical intervention, visual acuity and visual field remained stable or improved in the majority of the patients.
CONCLUSIONS: Endoscopic approaches are slowly gaining momentum for treatment of spheno-orbital meningiomas. Further studies on the clinical benefits of this approach on patient outcomes and post-operative complications is warranted.

Symptomatic cavernous malformations in the ventral region of the pons are difficult to access surgically. The authors present a case of a 46-year-old woman with a 10-year history of sudden and transitory diplopia and right hemiparesis, followed by five more episodes of mild right hemiparesis. Brain MRI showed a 2.6-cm cavernous malformation in the pons with an exophytic portion in the prepontine cistern. The patient underwent an endoscopic endonasal transclival approach for a complete resection of the lesion. CSF leak was noted and corrected on the sixth postoperative day. The patient progressed with complete motor deficit recovery. The video can be found here: https://youtu.be/ePgpyij2Wpo.

An 8-year-old child presented with fatigue, weight loss, and visual deterioration. MRI demonstrated a craniopharyngioma with compression of the optic chiasm and extensive edema on the hypothalamus and optic radiations. The tumor was completely removed via an endoscopic endonasal approach. Postoperatively, vision improved and hypothalamic edema completely resolved within 5 days. This video demonstrates the technical nuances of the surgery and discusses the impact of surgery on the hypothalamic nuclei in pediatric patients. The video can be found here: https://youtu.be/wxkBmhTPi6c.