Endoscopic skull base surgery complications [Neurosurgery Wiki]

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====== Endoscopic skull base surgery complications ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1TehQ7T6jkw_zgsuxpcp36U0Nzf3xN0ACgIYU_Sh-qKBZFKg5_/?limit=15&utm_campaign=pubmed-2&fc=20250126065221}}

Endoscopic skull base surgery is a minimally invasive technique that provides improved visualization and access to the skull base compared to traditional open approaches. However, like any surgical procedure, it carries potential complications. These complications can be broadly categorized into intraoperative and postoperative complications
((Sokoya M, Mourad M, Ducic Y. [[Complications]] of [[Skull Base Surgery]]. Semin Plast Surg. 2017 Nov;31(4):227-230. doi: 10.1055/s-0037-1607203. Epub 2017 Oct 25. PMID: 29075162; PMCID: PMC5656445.))

===== Retrospective case series combined with a literature review =====
Akins et al in a retrospective case series examine early and late complications in 60 patients undergoing open and endoscopic skull base and craniofacial surgeries at a single [[institution]], compared to a [[database]] of 2,143 craniotomies. Acute complications occurred in 38% of cases, while 17% experienced delayed complications, including [[cerebrospinal fluid leak]]s, [[diabetes insipidus]], and infections. Illustrative vignettes highlight complex cases. A [[literature review]] broadens the [[scope]], emphasizing the need for [[multidisciplinar]]y [[approaches]], longitudinal [[follow-up]], and improved [[perioperative]] [[protocol]]s to address unique [[risk]]s and optimize [[outcome]]s in complex skull base pathology
((Akins, P. T., Ledgerwood, L. G., & Duong, H. T. (2022). Early and late complications after open and endoscopic neurosurgery for complex skull base and craniofacial pathology: Case series, illustrative cases, and review. Interdisciplinary Neurosurgery, 29, 101552. https://doi.org/10.1016/j.inat.2022.101552))

===== Intraoperative Complications =====

==== Vascular Injuries ====

- **[[Carotid Artery Injury]]**: A life-threatening complication requiring immediate management, such as vessel repair, packing, or endovascular stenting.

- **Other Major Vessels**: Injuries to vessels like the anterior cerebral artery or cavernous sinus can lead to significant bleeding and potential ischemia.
  
==== Neural Injuries ====

- **Cranial Nerves**: Damage to cranial nerves (e.g., optic nerve, abducens nerve) during dissection can lead to visual deficits or diplopia.

- **Brain Tissue Injury**: Manipulation or accidental penetration into brain tissue, particularly during tumor resection.

==== Dural Tears ====

- Unintentional breaches in the dura can lead to cerebrospinal fluid (CSF) leakage.

==== Instrumentation Issues ====

- Damage caused by surgical tools, including thermal injuries from cautery devices.

===== Postoperative Complications =====

==== CSF Leak ====

- One of the most common complications, resulting from incomplete repair of dural defects. This can predispose patients to **meningitis**.

see [[Cerebrospinal fluid fistula after endoscopic skull base surgery]].

==== Infection ====

- **Meningitis**: Due to persistent CSF leaks or contamination.
- **Sinusitis**: Secondary to disruption of sinonasal anatomy.

==== Vascular Complications ====

- **Pseudoaneurysm**: Formation in vessels like the internal carotid artery due to intraoperative injury.
- **Stroke**: Due to vessel injury, vasospasm, or embolism.

==== Endocrine Disorders ====

- If the pituitary gland is involved, complications may include:
  - **[[Diabetes Insipidus]]**: From damage to the pituitary stalk or hypothalamus.
  - **[[Hypopituitarism]]**: Partial or complete loss of pituitary function.
  - **[[Syndrome of Inappropriate Antidiuretic Hormone Secretion]] (SIADH)**.

==== Vision Changes ====

- Worsening vision or new deficits due to [[optic nerve injury]], swelling, or vascular compromise.

==== Scarring and Adhesions ====

- In the [[sinonasal]] [[cavity]], leading to chronic [[nasal obstruction]] or loss of [[olfactory]] function.

==== Cosmetic Deformities ====

- Rare but may include nasal deformities or changes in the facial contour.



===== Patient-Related Risk Factors =====

- **Preexisting Conditions**: Previous surgery, radiation therapy, or infections can increase complication risks.

- **Tumor Characteristics**: Large, vascular, or invasive lesions increase procedural difficulty.

- **Anatomical Variations**: Variations like a low-lying optic nerve or abnormal vessel course.



===== Prevention and Management =====

- **Preoperative Planning**:
  - Use of imaging (CT, MRI) for anatomical and pathological assessment.
  - Multidisciplinary team involvement, including ENT surgeons and neurosurgeons.
- **Intraoperative Techniques**:
  - Navigation systems for precise localization.
  - Adequate repair of dural defects using grafts and sealants.
- **Postoperative Monitoring**:
  - Vigilant monitoring for signs of CSF leak, infection, or neurological changes.
  - Endocrine function assessments, particularly after pituitary surgeries.
- **Emergency Preparedness**:
  - Access to endovascular interventions for vascular injuries.

===== Retrospective observational studies =====

A retrospective study that included patients who underwent endoscopic skull base surgery with the creation of a nasoseptal flap, assessing for the presence of the following post-surgical complications: cerebrospinal fluid leak, meningitis, mucocele formation, nasal synechia, septal perforation (before posterior septectomy), internal nasal valve failure, epistaxis, and olfactory alterations.

Results: The study assessed 41 patients undergoing surgery. Of these, 35 had pituitary adenomas (macro- or micro-adenomas; sellar and suprasellar extension), three had meningiomas (two tuberculum sellae and one olfactory groove), two had craniopharyngiomas, and one had an intracranial abscess. The complications were cerebrospinal fluid leak (three patients; 7.3%), meningitis (three patients; 7.3%), nasal fossa synechia (eight patients; 19.5%), internal nasal valve failure (six patients; 14.6%), and complaints of worsening of the sense of smell (16 patients; 39%). The olfactory test showed anosmia or hyposmia in ten patients (24.3%). No patient had mucocele, epistaxis, or septal perforation.

The use of the nasoseptal flap has revolutionized endoscopic skull base surgery, making the procedures more effective and with lower morbidity compared to the traditional route. However, although mainly transient nasal morbidities were observed, in some cases, permanent hyposmia and anosmia resulted. An improvement in this technique is therefore necessary to provide a better quality of life for the patient, reducing potential complications
((Dolci RLL, Miyake MM, Tateno DA, Cançado NA, Campos CAC, Dos Santos ARL, Lazarini PR. Postoperative otorhinolaryngologic complications in transnasal endoscopic surgery to access the skull base. Braz J Otorhinolaryngol. 2017 May-Jun;83(3):349-355. doi: 10.1016/j.bjorl.2016.04.020. Epub 2016 May 31. PMID: 27320654; PMCID: PMC9444793.)).
----
In a retrospective review of patients undergoing endoscopic resection of [[paranasal sinus]] or [[skull base]] [[neoplasm]] from 2007 to 2013. Setting Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center. Participants Fifty-eight consecutive patients. Main Outcome Measures [[Postoperative]] [[complications]] were categorized as [[cerebrospinal fluid leak]], pituitary, orbital, intracranial, or sinonasal. Complications were temporally categorized as "[[perioperative]]" (within 1 week), "early" (after 1 week and within 6 months), or "delayed" (after 6 months). 
The most common perioperative complications were [[diabetes insipidus]] (19.0%), [[CSF leak]] (5.2%), and [[meningitis]] (5.2%), with resolution rates of 75%, 100%, and 100%, respectively. Overall, CSF leaks occurred in 13.8% of patients and was resolved in all cases. A total of 53.8% of all complications were evident within 1 week of surgery. Chronic [[rhinosinusitis]] was the most common delayed complication (3.4%). [[Hypopituitarism]] and delayed complications were less likely to resolve (p = 0.014 and p = 0.080, respectively).  Monitoring of complications after [[endoscopic skull base surgery]] should focus on neurologic complications and CSF leak in the early postoperative period and the development of chronic [[rhinosinusitis]] in the long term. Late-onset complications and [[hypopituitarism]] are less likely to resolve
((Naunheim MR, Sedaghat AR, Lin DT, Bleier BS, Holbrook EH, Curry WT, Gray ST. Immediate and Delayed Complications Following Endoscopic Skull Base Surgery. J Neurol Surg B Skull Base. 2015 Sep;76(5):390-6. doi: 10.1055/s-0035-1549308. Epub 2015 May 15. PMID: 26401482; PMCID: PMC4569498.))
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The study provides valuable insights into the temporal distribution and resolution of complications following endoscopic skull base surgery. However, its findings are limited by the retrospective design, small sample size, and single-center setting. Future studies with larger, multicenter cohorts and prospective methodologies are needed to validate these results and further refine perioperative and long-term management strategies for these patients.