Introduction
The most common type of brain malignancy in adults is metastatic brain tumor, in which approximately 30% of patients with primary cancers will develop brain disease. , Because of improvements in systemic therapies, there are more patients surviving with primary cancers, and thus a higher incidence of metastatic brain tumors. , This has resulted in more patients presenting with metastases in atypical cranial locations. An uncommon location for metastases is the skull base. These skull base metastases are challenging to manage because they are in close proximity to several critical neural and vascular structures. In this chapter, we present a case of a metastatic brain tumor involving the skull base.
Chief complaint: double vision and headaches
History of present illness
A 39-year-old, right-handed woman with a history of synovial sarcoma status post right renal and adrenal resection with negative margins for synovial sarcoma 2 years prior presented with headaches and double vision. Over 2 weeks, she complained of bifrontal headaches and double vision in which her left eye was unable to move outward. She denies any visual field deficits ( Fig. 38.1 ).
Medications : None.
Allergies : No known drug allergies.
Past medical and surgical history : Synovial sarcoma status post right nephrectomy/adrenalectomy with negative margins.
Family history : No history of intracranial malignancies.
Social history : Homemaker, no smoking and no alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Language: intact naming and repetition; Cranial nerves II to XII intact except cranial nerve VI palsy; No drift, moves all extremities with full strength.
Computed tomography chest/abdomen/pelvis : No evidence of systemic disease.
| Peter E. Fecci, MD, PhD, Duke University, Durham, NC, United States | Kenji Ohata, MD, PhD, Osaka City University, Osaka, Japan | Jamie J. Van Gompel, MD, Mayo Clinic, Rochester, MN, United States | Graeme F. Woodworth, MD, University of Maryland, Baltimore, MD, United States | |
|---|---|---|---|---|
| Preoperative | ||||
| Additional tests requested | CT/CT angiography Neuroophthalmology (visual fields) Endocrinology evaluation | CT angiography CT venography Angiogram (right ICA BTO) Thin slice CT | Angiogram (right ICA BTO) PET full body | Thin slice CT Angiogram Otolaryngology evaluation for biopsy |
| Surgical approach selected | Endoscopic endonasal | Endoscopic endonasal | Endoscopic endonasal | Endoscopic endonasal |
| Anatomic corridor | Endoscopic endonasal | Endoscopic endonasal transpterygoid | Endoscopic endonasal with right transpterygoid | Endoscopic endonasal trans-sphenoidal, trans-tuberculum |
| Goal of surgery | Diagnosis, relief of mass effect | Maximal resection, followed by possible adjuvant therapy | Maximal resection with inability to obtain negative margins | Maximal resection with cranial nerve decompression |
| Perioperative | ||||
| Positioning | Supine, no pins | Supine, right 15-degree rotation | Supine | Supine |
| Surgical equipment | Surgical navigation Endoscope Coblator Micro Doppler | Surgical navigation Endoscope Doppler IOM (VEP) | Surgical navigation Endoscope Endoscopic clips Retractable knife Endonasal drill Specialty suctions | Lumbar drain Surgical navigation Endoscope Surgical microscope available |
| Medications | Steroids | None | Tranexamic acid | Steroids |
| Anatomic considerations | ICA and branches, optic nerves, vidian nerves, pituitary gland, diaphragma sella, cavernous sinus walls, and cranial nerves | Maxillary sinus, vidian canal, pterygoid plate, sellar floor, optic canal, paraclival ICA, cavernous sinus, pituitary gland | ICA | Sinonasal anatomy, including sphenoid sinus, planum sphenoidale, tuberculum sella, cavernous/paraclival ICA, optic nerves, other cranial nerves |
| Complications feared with approach chosen | ICA injury, CSF leak | ICA injury, CSF leak | ICA and basilar artery injuries | ICA injury, optic apparatus injury, pituitary injury, CSF leak |
| Intraoperative | ||||
| Anesthesia | General | General | General | General |
| Skin incision | None | None | None | None |
| Bone opening | Transsphenoidal | Transpterygoid, transsphenoidal | Transpterygoid, transsphenoidal | Transsphenoidal, transtubercular, transplanum |
| Brain exposure | Pituitary gland | Pituitary gland | Pituitary gland | Pituitary gland, parasellar, anterior cranial fossa |
| Method of resection | Sphenoidotomy, preservation of bilateral nasoseptal flaps, micro Doppler probe and navigation to identify ICA and cavernous sinus, debulk with curettes and dissectors, maximal safe debulking; if CSF leak, abdominal fat, layered dural closure, nasoseptal flap, lumbar drain | Lateralize turbinates, harvest nasoseptal flap, complete sphenoidotomy, removal of right posteromedial wall of maxillary sinus and anteromedial portion of right pterygoid plate, ligation of SPA, follow right vidian canal, removal of tumor, removal of tuberculum sellae and medial part of optic canal, exposure and mobilization of right paraclival ICA, resect in sella, cavernous sinus, multilayer reconstruction with collagen matrix, abdominal fat, nasoseptal flap | Harvest large nasoseptal flap, right middle turbinate resection, posterior ethmoidectomies, large sphenoid antrostomy, removal of tumor, drill out involved bone, fat in clival recess, nasoseptal flap, lumbar drain if CSF leak | Lumbar drain insertion, binarial access, bimanual dissection, posterior septectomy, expanded parasellar exposure, bimanual resection of tumor, nasal septal flap |
| Complication avoidance | Micro Doppler, limit to safe resection, nasoseptal flap for CSF leak | Wide exposure, mobilization of right paraclival ICA, large nasoseptal flap | Wide exposure, large nasoseptal flap | Lumbar drain insertion, wide exposure, nasoseptal flap |
| Postoperative | ||||
| Admission | ICU | ICU | ICU or floor depending on dural entry | ICU |
| Postoperative complications feared | CSF leak, ICA injury, endocrinopathy, diplopia, visual decline | Extraocular movement disorders, pituitary dysfunction | CSF leak, carotid artery injury | CSF leak, carotid artery injury, cranial neuropathy |
| Follow-up testing | MRI within 48 hours after surgery 1 day after surgery morning cortisol, electrolytes | CT immediately after surgery MRI within 1 week after surgery Pituitary function 1 week after surgery | MRI within 24 hours after surgery and 3 months after surgery | CT immediately after surgery |
| Follow-up visits | 6 weeks after surgery 1 week with endocrine and ENT | 1 week after surgery | 2 weeks after surgery | 2 and 6 weeks after surgery |
| Adjuvant therapies recommended | Fractionated radiotherapy | Radiation/chemotherapy | Proton beam therapy | Radiation therapy |
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
