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Méndez Rosito D, Borrayo-Dorado S, Zorrilla-Madera E, Sánchez-Gallardo JF, Gallardo-Ceja D, Ríos FJ, Cárdenas Y, Palmisciano P, Forbes JA, Abdala-Vargas NJ. The M-Point A Novel Landmark in Middle Fossa Surgery: A Cadaveric Morphometric Study. World Neurosurg 2024; 181:e67-e74. [PMID: 37385439 DOI: 10.1016/j.wneu.2023.06.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND The arcuate eminence (AE) is an anatomically consistent bony protrusion located on the upper surface of the petrous bone that has been previously studied as a reference for lateral skull base approaches. There is a paucity of information in the neurosurgical literature seeking to improve the safety of the extended middle cranial fossa (MCF) approach using detailed morphometric analysis of the AE. OBJECTIVE To evaluate the use of the AE as an anatomical landmark to help with early identification of the internal acoustic canal (IAC) in MCF approaches by means of a cadaveric study, using a new morphometric reference termed the "M-point." METHODS A total of 40 dry temporal bones and 2 formalin-preserved, latex-injected cadaveric heads were used. The M-point was established as a new anatomic reference by identifying the intersection of a line perpendicular to the alignment of the petrous ridge (PR), originating from the midpoint of the AE, with the PR itself. Subsequent anatomical measurements were performed to measure the distance between M-point and IAC. Additional distances, including PR length and the anteroposterior and lateral AE surfaces, were also measured. RESULTS The mean distance between the M-point and the center of the IAC was 14.9 mm (SD ± 2.09), offering a safe drilling area during an MCF approach. CONCLUSIONS This study provides novel information on identification of a new anatomic reference point known as the M-point that that can be used to improve early surgical identification of the IAC.
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Affiliation(s)
- Diego Méndez Rosito
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico.
| | - Sheila Borrayo-Dorado
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Elias Zorrilla-Madera
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | | | - David Gallardo-Ceja
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Francisco J Ríos
- Department of Anatomy, Escuela Superior de Medicina, IPN, Mexico City, Mexico
| | - Yolanda Cárdenas
- Department of Anatomy, Escuela Superior de Medicina, IPN, Mexico City, Mexico
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan A Forbes
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nadin J Abdala-Vargas
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico; Department of Neurological Surgery, Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital de San José, Bogotá, Colombia
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Baucher G, Troude L, Olory-Togbe R, Roche PH. Extradural disconnection of the cavernous sinus with preservation of the internal carotid artery: indication and technique. Acta Neurochir (Wien) 2023; 165:2951-2956. [PMID: 36971846 DOI: 10.1007/s00701-023-05562-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/09/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Extradural disconnection of the cavernous sinus (CS) with preservation of the internal carotid artery (ICA) is indicated for aggressive and recurrent tumors, in patients presenting loss of oculomotor function and non-functional circle of Willis. METHOD Extradural resection of the anterior clinoid process disconnects the CS anteriorly. The ICA is dissected in the foramen lacerum via extradural subtemporal approach. The intracavernous tumor is split and removed following the ICA. Bleeding control of the inferior and superior petrosal and intercavernous sinuses completes posterior CS disconnection. CONCLUSION This technique can be proposed for recurrent CS tumors and need of ICA preservation.
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Affiliation(s)
- Guillaume Baucher
- AP-HM, Hôpital Universitaire Nord, Neurochirurgie adulte, Chemin des Bourrely , 13015, Marseille, France.
| | - Lucas Troude
- AP-HM, Hôpital Universitaire Nord, Neurochirurgie adulte, Chemin des Bourrely , 13015, Marseille, France
| | - Régis Olory-Togbe
- AP-HM, Hôpital Universitaire Nord, Neurochirurgie adulte, Chemin des Bourrely , 13015, Marseille, France
| | - Pierre-Hugues Roche
- AP-HM, Hôpital Universitaire Nord, Neurochirurgie adulte, Chemin des Bourrely , 13015, Marseille, France
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Beucler N, Dagain A. Decompressive craniectomy: keep it simple! Acta Neurochir (Wien) 2023; 165:2377-2379. [PMID: 35717427 DOI: 10.1007/s00701-022-05280-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, 2 boulevard Sainte-Anne, 83800, Toulon Cedex 9, France.
- Ecole du Val-de-Grâce, French Military Health Service Academy, 1 place Alphonse Laveran, 75230, Paris Cedex 5, France.
| | - Arnaud Dagain
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, 2 boulevard Sainte-Anne, 83800, Toulon Cedex 9, France
- Val-de-Grâce Military Academy, 1 place Alphonse Laveran, 75230, Paris Cedex 5, France
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Sahana D, Rathore L, Kumar S, Jain A, Tawari M, Sahu R. Internal Acoustic Meatus Localization During Anterior Petrosectomy: A Novel Technique. World Neurosurg 2023; 175:e1255-e1264. [PMID: 37141941 DOI: 10.1016/j.wneu.2023.04.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE Anterior petrosectomy demands localization of the internal auditory canal (IAC) for safe bone drilling and maximum exposure. Various techniques have been described in the literature, each with shortcomings. We propose a new technique to localize the internal acoustic meatus (IAM) using more consistent anatomical landmarks. METHODS The study was done in three phases. In phase-I (radiological), computed tomography scan heads of fifty patients (100 sides) were analyzed. Arcuate eminence-Greater Superficial Petrosal Nerve bifurcation angle(Garcia-Ibanez technique), Arcuate eminence-IAC angle(Fisch technique) and a new angle formed between foramen ovale (FO) and foramen spinosum (FS) line, and FS and IAM line (FO-FS-IAM angle) was measured. The mean, standard deviation, and variance were calculated. In phase-II (cadaveric), the FO-FS-IAM angle was measured on five (10 sides) dry skulls. In phase-III (clinical), the IAM was localized using the FO-FS-IAM angle in 13 patients. RESULTS The mean angle between arcuate eminence and Greater Superficial Petrosal Nerve (Garcia-Ibanez technique) was 126.20 ± 11.63°(range 106-156) with a variance of 135.20. The mean bifurcation angle was 63 ± 5.81°(range 53-78). By the Fisch technique, the mean arcuate-IAM angle was 73.5 ± 11.70°(range 51-105) with a variance of 137.18. By our technique, the mean FO-FS-IAM angle was 94.72 ± 5.89°(range 84-108). The variance was 34.73. The mean FO-FS-IAM angle on dry skulls was identical (95 ± 1.97°) to our radiological measurements. This angle was reproduced reliably in clinical cases for localizing the IAM during anterior petrosectomy. CONCLUSIONS The FO-FS-IAM angle variance was much lower than the analogous angles measured by Garcia-Ibanez and Fisch techniques, making it a more reliable and effective tool for localizing the IAM.
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Affiliation(s)
- Debabrata Sahana
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center Raipur, Chhattisgarh, India.
| | - Lavlesh Rathore
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center Raipur, Chhattisgarh, India
| | - Sanjeev Kumar
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center Raipur, Chhattisgarh, India
| | - Amit Jain
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center Raipur, Chhattisgarh, India
| | - Manish Tawari
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center Raipur, Chhattisgarh, India
| | - Rajiv Sahu
- Department of Neurosurgery, DKS Post Graduate Institute and Research Center Raipur, Chhattisgarh, India
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Fava A, Gorgoglione N, De Angelis M, Esposito V, di Russo P. Key role of microsurgical dissections on cadaveric specimens in neurosurgical training: Setting up a new research anatomical laboratory and defining neuroanatomical milestones. Front Surg 2023; 10:1145881. [PMID: 36969758 PMCID: PMC10033783 DOI: 10.3389/fsurg.2023.1145881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/13/2023] [Indexed: 03/12/2023] Open
Abstract
IntroductionNeurosurgery is one of the most complex surgical disciplines where psychomotor skills and deep anatomical and neurological knowledge find their maximum expression. A long period of preparation is necessary to acquire a solid theoretical background and technical skills, improve manual dexterity and visuospatial ability, and try and refine surgical techniques. Moreover, both studying and surgical practice are necessary to deeply understand neuroanatomy, the relationships between structures, and the three-dimensional (3D) orientation that is the core of neurosurgeons' preparation. For all these reasons, a microsurgical neuroanatomy laboratory with human cadaveric specimens results in a unique and irreplaceable training tool that allows the reproduction of patients' positions, 3D anatomy, tissues' consistencies, and step-by-step surgical procedures almost identical to the real ones.MethodsWe describe our experience in setting up a new microsurgical neuroanatomy lab (IRCCS Neuromed, Pozzilli, Italy), focusing on the development of training activity programs and microsurgical milestones useful to train the next generation of surgeons. All the required materials and instruments were listed.ResultsSix competency levels were designed according to the year of residency, with training exercises and procedures defined for each competency level: (1) soft tissue dissections, bone drilling, and microsurgical suturing; (2) basic craniotomies and neurovascular anatomy; (3) white matter dissection; (4) skull base transcranial approaches; (5) endoscopic approaches; and (6) microanastomosis. A checklist with the milestones was provided.DiscussionMicrosurgical dissection of human cadaveric specimens is the optimal way to learn and train on neuroanatomy and neurosurgical procedures before performing them safely in the operating room. We provided a “neurosurgery booklet” with progressive milestones for neurosurgical residents. This step-by-step program may improve the quality of training and guarantee equal skill acquisition across countries. We believe that more efforts should be made to create new microsurgical laboratories, popularize the importance of body donation, and establish a network between universities and laboratories to introduce a compulsory operative training program.
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Affiliation(s)
- Arianna Fava
- Department of Neurosurgery, IRCCS Neuromed, Pozzilli, Italy
- Department of Neuroscience, Sapienza University, Rome, Italy
- Correspondence: Arianna Fava
| | | | | | - Vincenzo Esposito
- Department of Neurosurgery, IRCCS Neuromed, Pozzilli, Italy
- Department of Neuroscience, Sapienza University, Rome, Italy
| | - Paolo di Russo
- Department of Neurosurgery, IRCCS Neuromed, Pozzilli, Italy
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Yan Y, Xu T, Zhao Y, Mei Q, Jiang L, Hou L. Exposure region of the Kawase approach and its correlation with skull base anatomy: An evaluation with digital models. Front Surg 2023; 9:1047949. [PMID: 36684198 PMCID: PMC9852744 DOI: 10.3389/fsurg.2022.1047949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/21/2022] [Indexed: 01/09/2023] Open
Abstract
The Kawase approach is one of the most used trajectories in skull base surgery. The exposure range of the approach and its correlation with skull base anatomy still demand more exploration. With the help of digital rebuilding, analysis, and measurement, we evaluated the exposure range of the Kawase and extended Kawase approaches and analyzed the correlation between the exposure range and the variants of the petrosal and clival anatomy. The finding of the study demonstrated that compared to the sub-temporal approach, the Kawase approach and the extended Kawase approach significantly added the exposure range in the upper, middle, and partial inferior regions of the clivus. The gains in the exposure volume and area are more when the manipulation angle is less than 135°.
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Affiliation(s)
- Yong Yan
- Correspondence: Yong Yan Lijun Hou
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Roux A, Troude L, Baucher G, Bernard F, Pallud J, Roche PH. Does general comorbidity impact the postoperative outcomes after surgery for large and giant petroclival meningiomas? Neurosurg Rev 2021; 45:617-626. [PMID: 34117561 DOI: 10.1007/s10143-021-01580-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/17/2021] [Accepted: 06/07/2021] [Indexed: 02/07/2023]
Abstract
We assessed the role of the general condition of the patient in addition to usual anatomical reasoning to improve the prediction of personalized surgical risk for patients harboring a large and giant petroclival meningiomas. Single-center, retrospective observational study including adult patients surgically treated for a large and giant petroclival meningioma between January 2002 and October 2019 in a French tertiary neurosurgical skull-base center by one Neurosurgeon. Inclusion criteria were as follows: (1) histopathologically proven meningioma; (2) larger than 3 cm in diameter; (3) located within the upper two-thirds of the clivus, the inferior petrosal sinus, or the petrous apex around the trigeminal incisura, medial to the trigeminal nerve. Clinical and radiological characteristics were gathered preoperatively including ASA score, the modified frailty index, and the Charlson comorbidity index. Post-operative severe neurological and non-neurological complications were collected. A total of 102 patients harboring a large and giant petroclival meningioma were included. The rate of postoperative death was 3.0% related to a congestive heart failure (n = 1), a surgical site hematoma (n = 1), and an ischemic stroke (n = 1). A severe neurological impairment was found in 12.8% and a severe non-neurological morbidity was found in 4.0%. The overall rate of severe morbidity and mortality was 15.7% after large and giant petroclival meningioma surgery. The presence of brainstem peri-tumoral edema (adjusted OR, 4.83 [95% CI 1.84-7.52], p = 0.028) was independently associated with a history of postoperative severe neurological morbidity. Male gender (adjusted OR, 7.42 [95% CI 1.05-49.77], p = 0.044), major cardiovascular morbidity (adjusted OR, 9.5 [95% CI 1.05-86.72], p = 0.045), and an ASA score ≥ 2 (adjusted OR, 11.09 [95% CI 1.46-92.98], p = 0.038) were independently associated with a history of postoperative severe non-neurological morbidity. A modified frailty index ≥ 1 (adjusted OR, 3.13 [95% CI 1.07-9.93], p = 0.047) and a low neurosurgical experience (adjusted OR, 5.38 [95% CI 1.38-20.97], p = 0.007) were independently associated with a history of postoperative overall morbidity and mortality. Pre-operative cranial nerve deficits (adjusted OR, 4.77 [95% CI 1.02-23.31], p = 0.024) and gross total resection (adjusted OR, 10.72 [95% CI 1.72-66.90], p = 0.022) were independently associated with postoperative new cranial nerve deficits. This study suggests to add scores assessing the patient general condition in daily practice to improve the selection of patients eligible for surgery. Collaborative international multicenter studies will be necessary to confirm these results and allow their implementation in clinical routine.
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Affiliation(s)
- Alexandre Roux
- Service de Neurochirurgie, GHU Paris - Psychiatrie et Neurosciences - Hôpital Sainte-Anne, 1 rue Cabanis, 75014, Paris, France.
- Université de Paris, Sorbonne Paris Cité, Paris, France.
- Inserm, UMR1266, IMA-Brain, Institut de Psychiatrie Et Neurosciences de Paris, Paris, France.
| | - Lucas Troude
- Service de Neurochirurgie, CHU Nord, APHM-AMU, Marseille, France
| | | | - Florian Bernard
- Service de Neurochirurgie, CHU Angers, 49100, Angers, France
| | - Johan Pallud
- Service de Neurochirurgie, GHU Paris - Psychiatrie et Neurosciences - Hôpital Sainte-Anne, 1 rue Cabanis, 75014, Paris, France
- Université de Paris, Sorbonne Paris Cité, Paris, France
- Inserm, UMR1266, IMA-Brain, Institut de Psychiatrie Et Neurosciences de Paris, Paris, France
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8
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How I do it: retrosigmoid intradural inframeatal petrosectomy. Acta Neurochir (Wien) 2021; 163:649-653. [PMID: 32989518 PMCID: PMC7886824 DOI: 10.1007/s00701-020-04587-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/15/2020] [Indexed: 11/01/2022]
Abstract
BACKGROUND Lesions infiltrating the petrous temporal bone are some of the most complex to treat surgically. Many approaches have been developed in order to address these lesions, including endoscopic endonasal, anterior petrosectomy, posterior petrosectomy, and retrosigmoid. METHOD We describe in a stepwise fashion the surgical steps of the retrosigmoid intradural inframeatal petrosectomy. CONCLUSION The retrosigmoid intradural inframeatal petrosectomy may afford satisfactory exposure with limited drilling and minimal disruption of perilesional anatomical structures. It can provide excellent surgical results, especially for soft tumors, while minimizing surgical morbidity.
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Rutledge C, Raper DMS, Raygor KP, Budohoski KP, Abla AA. Limited Intradural Anterior Petrosectomy for Upper Basilar Aneurysms: A Technical Note. World Neurosurg 2021; 149:111-116. [PMID: 33640529 DOI: 10.1016/j.wneu.2021.02.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The extradural anterior petrosectomy is a widely used skull base approach to the upper petroclival region, basilar trunk, and ventral pons. However, there is significant procedure-related morbidity and a complete petrosectomy is required, as the intradural structures are not in view at the time of drilling. We describe an intradural anterior petrosectomy for aneurysms of the basilar trunk and anterior inferior cerebellar artery with intraoperative photographs and artwork to illustrate the approach. METHODS A temporal craniotomy is made at the root of the zygoma and middle fossa floor. After opening dura, the trochlear nerve is identified at the tentorial edge. The tentorium is incised posterior to the trochlear nerve and the incision is carried forward across the cisternal segment of the trigeminal nerve toward V3 and the superior petrosal sinus. The petrous apex is identified and drilled lateral and posterior to V3 with a diamond bur. Intraoperative navigation is useful to confirm its location. Once posterior fossa dura is identified, the superior petrosal sinus may be safely cauterized and divided, connecting the tentorial incision with an incision in the posterior fossa dura, and exposing the upper basilar trunk and its branches. Additional bone is removed only as needed. RESULTS Two patients underwent successful treatment of a basilar trunk perforator and anterior inferior cerebellar artery aneurysm with a subtemporal approach and tailored intradural petrosectomy. CONCLUSIONS The intradural anterior petrosectomy allows limited drilling of the petrous apex and provides sufficient exposure of upper basilar artery aneurysms.
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Affiliation(s)
- Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Karol P Budohoski
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California, USA.
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Suero Molina E, Revuelta Barbero JM, Ewelt C, Stummer W, Carrau RL, Prevedello DM. Access to Meckel's cave for biopsies of indeterminate lesions: a systematic review. Neurosurg Rev 2021; 44:249-259. [PMID: 32040778 PMCID: PMC7850998 DOI: 10.1007/s10143-020-01247-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/20/2020] [Indexed: 01/12/2023]
Abstract
Accessing Meckel's cave (MC) is surgically challenging. Open approaches are complex and often correlated with high morbidity. Endoscopic approaches emerged in the last decade as feasible alternatives to open approaches, especially for sampling indeterminate lesions. This article first analyses available routes to approach Meckel's cave and presents furthermore an illustrative case. We conducted a systematic review and reported according to the guidelines for preferred reporting items for systematic reviews and meta-analyses (PRISMA). Various surgical approaches identified through the search are evaluated and discussed in detail. Additionally, we report on a case of woman with a lesion in MC, which was accessed through an endoscopic transpterygoid approach subsequently diagnosed as a diffuse large B cell lymphoma. Our search delivered 75 articles that included case reports (n = 21), cadaveric studies (n = 32), clinical articles (n = 16), review of the literatures (n = 3), as well as technical notes (n = 2) and a radiological manuscript (n = 1). Open routes included lateral approaches with many variations, mainly intra- and extradural pterional approaches and anterior petrosal, as well as a retrosigmoid intradural suprameatal and a lateral transorbital approach. Endoscopically, MC was reached via approaches that included transpterygoid, transorbital or infraorbital fissure routes. Percutaneous approaches, e.g. through the foramen ovale, were also described. Multiple surgical approaches to MC are currently available. Their different characteristics as well as individual patient factors, such as clinical history and the localization of the disease, have to be considered when choosing a surgical corridor. Studies included in this review highlight the endonasal endoscopic transpterygoidal technique as an excellent corridor for biopsies in the ventral MC.
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Affiliation(s)
- E Suero Molina
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149, Munster, Germany.
| | - J M Revuelta Barbero
- Department of Otolaryngology-Head and Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
- Department of Neurological Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - C Ewelt
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149, Munster, Germany
| | - W Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149, Munster, Germany
| | - R L Carrau
- Department of Otolaryngology-Head and Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
- Department of Neurological Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - D M Prevedello
- Department of Otolaryngology-Head and Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
- Department of Neurological Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
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11
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Volovici V, Dammers R, Dirven CMF, Delwel EJ. Conquering the Rock-A Retrospective Single-Center Experience of the Transapical Petrosal Transtentorial (Kawase) Approach: Operative Technique and Impact on Cranial Nerve Function. J Neurol Surg B Skull Base 2020; 81:526-535. [PMID: 33209567 DOI: 10.1055/s-0039-1692485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 05/11/2019] [Indexed: 10/26/2022] Open
Abstract
Since its description in 1985, the transapical petrosal transtentorial or Kawase approach has become a viable option of approaching lesions located in and around the apex of the petrous bone, Meckel's cave, and the anterolateral surface of the brain stem while preserving cranial nerve function. At the Brain Tumor Center, Erasmus MC, 25 patients were treated using the Kawase approach between 2004 and 2018 for various indications, including petroclival meningiomas, chondrosarcomas, pontine cavernomas, trigeminal schwannomas, and posterior circulation aneurysms. Hearing preservation was achieved in all patients; new abducens nerve and trochlear nerve palsies were present in three and six patients, respectively, of which a total of eight required ophthalmological correction. Seven patients experienced a cerebrospinal fluid fistula postoperatively, but this complication appeared self-limiting in all cases, with one patient experiencing secondary meningitis. After modifying our closure technique, the rate of fistulas dropped to zero. The observed direct postoperative mortality was 4% (one patient), although not related to the approach itself. In conclusion, the Kawase approach is a highly complex, but essential middle fossa approach, extremely robust, and able to serve a wide array of pathologies together with its extensions. It is very accurate for performing hearing preservation surgery, but not without caveats and inherent risk of complications.
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Affiliation(s)
- V Volovici
- Division of Skull Base, Department of Neurosurgery, Academic Center of Excellence in Skull Base Surgery, Brain Tumor Center, Erasmus MC Stroke Center, Erasmus MC, Rotterdam, The Netherlands.,Department of Medical Decision Making, Erasmus MC, Rotterdam, The Netherlands
| | - R Dammers
- Division of Skull Base, Department of Neurosurgery, Academic Center of Excellence in Skull Base Surgery, Brain Tumor Center, Erasmus MC Stroke Center, Erasmus MC, Rotterdam, The Netherlands
| | - C M F Dirven
- Division of Skull Base, Department of Neurosurgery, Academic Center of Excellence in Skull Base Surgery, Brain Tumor Center, Erasmus MC Stroke Center, Erasmus MC, Rotterdam, The Netherlands
| | - E J Delwel
- Division of Skull Base, Department of Neurosurgery, Academic Center of Excellence in Skull Base Surgery, Brain Tumor Center, Erasmus MC Stroke Center, Erasmus MC, Rotterdam, The Netherlands
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Hasanbelliu A, Andaluz N, Di Somma A, Keller JT, Zimmer LA, Samy RN, Pensak ML, Zuccarello M. Extended Anterior Petrosectomy Through the Transcranial Middle Fossa Approach and Extended Endoscopic Transsphenoidal-Transclival Approach: Qualitative and Quantitative Anatomic Analysis. World Neurosurg 2020; 138:e405-e412. [PMID: 32145421 DOI: 10.1016/j.wneu.2020.02.127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Petroclival tumors and ventrolateral lesions of the pons present unique surgical challenges. This cadaveric study provides qualitative and quantitative anatomic comparison for an anterior petrous apicectomy through the transcranial middle fossa (TMF) and expanded endoscopic transsphenoidal-transclival approaches. METHODS In 10 silicone-injected heads, the petrous apex and clivus were drilled extradurally using middle fossa and endonasal approaches. With in situ and frameless stereotactic navigation, we defined consistent points to compare working areas, bone removal volumes, approach angles, and surgical freedom. RESULTS Mean exposed TMF area (21.03 ± 3.46 cm2) achieved a 44.71 ± 4.13° working angle to the brainstem between cranial nerves V and VI. Kawase's rhomboid area measured 1.76 ± 0.34 cm2, and bone removal averaged 1.20 ± 0.12 cm3 at the petrous apex. Surgical freedom on the lateral brainstem was higher halfway between cranial nerves V and VI at the center of the rhomboid compared with midline at the basilar sulcus (P < 0.01). After clivectomy and petrous apicectomy, mean exposed expanded endoscopic transsphenoidal-transclival area was 5.29 ± 0.66 cm2. Approach from either nostril showed no statistically significant differences in surgical freedom at the foramen lacerum and midpoint basilar sulcus. At the petrous apex, bone volume removed and area exposed were significantly larger for the TMF approach (P < 0.001). CONCLUSIONS Expanded transclival anterior petrosectomy through the TMF approach provides an adequate corridor to lesions in the upper ventrolateral pons. The expanded endoscopic transsphenoidal-transclival approach better fits midline lesions not extending laterally beyond cranial nerve VI and C3 carotid when evaluating normal anatomic parameters.
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Affiliation(s)
- Aurel Hasanbelliu
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Norberto Andaluz
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Brain Tumor Center at University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio, USA; Mayfield Clinic, Cincinnati, Ohio, USA.
| | - Alberto Di Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università; degli Studi di Napoli Federico II, Naples, Italy
| | - Jeffrey T Keller
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Brain Tumor Center at University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio, USA
| | - Lee A Zimmer
- Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Brain Tumor Center at University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio, USA; Mayfield Clinic, Cincinnati, Ohio, USA
| | - Ravi N Samy
- Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Brain Tumor Center at University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio, USA
| | - Myles L Pensak
- Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Brain Tumor Center at University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio, USA
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA; Brain Tumor Center at University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio, USA
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Spiessberger A, Baumann F, Stauffer A, Marbacher S, Kothbauer KF, Fandino J, Moriggl B. Extended exposure of the petroclival junction: The combined anterior transpetrosal and subtemporal/transcavernous approach. Surg Neurol Int 2019; 9:259. [PMID: 30687570 PMCID: PMC6322168 DOI: 10.4103/sni.sni_298_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 12/02/2018] [Indexed: 11/17/2022] Open
Abstract
Background: The combined anterior transpetrosal and subtemporal/transcavernous (atsta) approach to the petroclival junction provides a wide exposure facilitating resection of large tumor lesions such as petroclival mengiomas, chondrosarcomas, or chordomas. In this article we provide technical instructions on the approach with anatomical consideration and a literature review of previous applications of this approach. Methods: The combined approach was performed in two cadaveric specimen and relevant anatomical aspects were studied. Additionally, the authors performed a review of the literature focusing on indications, neurologic outcome, and complications associated with the technique. Results: A combined atsta approach offers a wide exposure of the crus cerebrum, pons, basal temporal lobe, cranial nerves III to VII/VIII, posterior cerebral artery (PCA), superior cerebellar artery (SCA), basilar artery (BA), anterior inferior cerebellar artery (AICA), and posterior communicating artery (Pcom). It has been successfully applied with acceptable morbidity and mortality rates, mainly for (spheno-) petroclival meningiomas. Conclusion: The combined approach studied here is a useful skull base approach to the petroclival junction and can be applied to treat large or complex pathologies of the region. Detailed anatomical knowledge is essential.
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Affiliation(s)
| | - Fabian Baumann
- Department of Neurosurgery, Luzerner Kantonsspital, Spitalstrasse, 6000 Luzern/Switzerland
| | - Alexandra Stauffer
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 1, 5001 Aarau/Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 1, 5001 Aarau/Switzerland
| | - Karl F Kothbauer
- Department of Neurosurgery, Luzerner Kantonsspital, Spitalstrasse, 6000 Luzern/Switzerland.,Universität Basel, Petersplatz 1, 4001 Basel/Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 1, 5001 Aarau/Switzerland
| | - Bernhard Moriggl
- Department of Anatomy, Histology and Embryology, Medical University of Innsbruck (MUI), 6020 Innsbruck/Austria
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Troude L, Carissimi M, Lavieille JP, Roche PH. How I do it: the combined petrosectomy. Acta Neurochir (Wien) 2016; 158:711-715. [PMID: 26876566 DOI: 10.1007/s00701-016-2740-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Petroclival and ventral brain stem tumors require a complex approach. METHOD The combined petrosectomy is an epidural transtentorial-transpetrosal otoneurosurgical approach to achieve a retrolabyrinthine presigmoidal approach and an anterior petrosectomy in one single procedure. The different steps of this approach are described and illustrated by figures and a video. The indications and limitations of the technique are presented. CONCLUSION The combined petrosectomy offers multiple corridors to the petroclival region and ventral brainstem while preserving the intrapetrous neurotological structures. Meticulous stepwise bony resection optimizing the dural opening and preservation of veins contributes to reducing the risk inherent to this technique.
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Anatomic comparison of anterior petrosectomy versus the expanded endoscopic endonasal approach: interest in petroclival tumors surgery. Surg Radiol Anat 2015; 37:1199-207. [PMID: 26067921 DOI: 10.1007/s00276-015-1497-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/23/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Since the petroclival region is deep-seated with close neurovascular relationships, the removal of petroclival tumors still represents a fascinating surgical challenge. Although the classical anterior petrosectomy (AP) offers a meaningful access to this petroclival region, the expanded endoscopic endonasal approach (EEEA) recently leads to overcome difficulties from trans-cranial approaches. Herein, we present an anatomic comparison of AP versus EEEA. We aim to describe the limits of these both approaches helping the choice of the optimal surgical route for petroclival tumors. METHODS Six fresh cadaveric heads were harvested and injected with colored latex. Each approach was step-by-step detailed until its final surgical exposure. RESULTS The AP provided a narrow direct supero-lateral access to the petroclival area that can also reach the cavernous sinus, the retrochiasmatic region and perimesencephalic cisterns. However, this corridor anterior to the internal acoustic meatus passed on each side of the trigeminal nerve. Moreover, tumor extensions toward the foramen jugularis, inside the clivus or behind the internal acoustic meatus were difficult to control. The EEEA brought a straightforward access to the clivus but the petrous apex was hidden behind the internal carotid artery. Several variants were described: a medial transclival, a lateral through the Meckel's cave and an inferior trans-pterygoid route. Elsewhere, tumor extension behind the internal acoustic meatus or above the tentorium could not be satisfactorily assessed. DISCUSSION AND CONCLUSION PA and EEEA have their own limits in reaching the petroclival region in accordance with the tumor characteristics. The AP should be preferred for radical removal of middle-sized petrous apex intradural tumors like meningiomas. The EEEA would be of interest for extradural midline tumors like chordomas or for petrous apex cysts drainage.
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Jacquesson T, Berhouma M, Tringali S, Simon E, Jouanneau E. Which Routes for Petroclival Tumors? A Comparison Between the Anterior Expanded Endoscopic Endonasal Approach and Lateral or Posterior Routes. World Neurosurg 2015; 83:929-36. [PMID: 25700970 DOI: 10.1016/j.wneu.2015.02.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 01/30/2015] [Accepted: 02/02/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Petroclival tumors remain a surgical challenge. Classically, the retrosigmoid approach (RSA) has long been used to reach such tumors, whereas the anterior petrosectomy (AP) has been proposed to avoid crossing cranial nerves. More recently, the endoscopic endonasal approach has been "expanded" (i.e., EEEA) to the petroclival region. We aimed to compare these 3 approaches to help in the surgical management of petroclival tumors. METHODS Petroclival approaches were performed on 5 specimens after they were prepared with formaldehyde colored via latex injection. RESULTS The EEEA provides a simple straightforward route to the clivus, but reaching the petrous apex requires the surgeon to circumvent the internal carotid artery either via a medial transclival, an inferior transpterygoid, or a lateral variant through the Meckel's cave. In contrast, the AP offers a narrow direct superolateral access to the petroclival region crossed by the trigeminal nerve. Finally, the RSA provides a wide simple and quick exposure of the cerebellopontine angle, but access to the petroclival region needs the surgeon to deal with the V(th) to XI(th) cranial nerves. DISCUSSION/CONCLUSION The EEEA should be preferred for extradural midline tumors (chordomas, chondrosarcomas) or for cystic lesions when drainage is essential. The AP could be optimal for the radical removal of intradural vascularized tumors (meningiomas) with intrapetrous or supratentorial extensions. The RSA retains an advantage for small or cystic tumors near the internal acoustic meatus. The skull base surgeon has to master all of these routes to choose the more appropriate one according to the surgical objective, the tumor characteristics, and the patient's medical status.
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Affiliation(s)
- Timothée Jacquesson
- Skull Base Multidisciplinary Unit, Department of Neurosurgery, Neurological Hospital Pierre Wertheimer, Lyon Cedex, France; Department of Anatomy, University of Lyon, Lyon, France.
| | - Moncef Berhouma
- Skull Base Multidisciplinary Unit, Department of Neurosurgery, Neurological Hospital Pierre Wertheimer, Lyon Cedex, France
| | - Stéphane Tringali
- Skull Base Multidisciplinary Unit, Department of Neurosurgery, Neurological Hospital Pierre Wertheimer, Lyon Cedex, France; Department of Otorhinolaryngology, Pierre Benite, France
| | - Emile Simon
- Department of Anatomy, University of Lyon, Lyon, France
| | - Emmanuel Jouanneau
- Skull Base Multidisciplinary Unit, Department of Neurosurgery, Neurological Hospital Pierre Wertheimer, Lyon Cedex, France
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The epidural approach to the Meckel's cave: a how I do it. Acta Neurochir (Wien) 2014; 156:217-20. [PMID: 24193888 DOI: 10.1007/s00701-013-1916-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 10/07/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Meckel's cave (MC) is a meningeal cleft lying in the middle fossa laterally to the cavernous sinus. Tumours that develop inside the MC may require a surgical resection. The authors describe the surgical technique of the intracranial epidural approach to the MC. METHODS Based upon anatomical dissection showing the relevant surgical anatomy, and illustrated by the video of an operated case, the authors detail the surgical procedure. The key point is to shave the floor of the middle fossa and skeletonize the superior orbital fissure, rotundum and ovale foramen in order to delineate the plane of dural elevation and expose the lateral wall of the MC. The rules of exposure and resection of the tumour are then shown. Variations and limitations of the approach are discussed. CONCLUSION Conducted in a stepwise manner and following relevant landmarks, the epidural anterolateral approach offers a safe and reliable exposure to the diseases that develop within the MC.
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