1
|
Wu Y, Wu X, Zhang YZ, Wu YX, Zhu G, Li ZH, Luo JN, Xue YF, Cheng HB, Lv ZQ, Gao GD, Qu Y, Zhao TZ. A Six-Surface System to Describe Anatomy of Anterior Clinoid Process and Its Application in Anterior Clinoidectomy and Resection of Paraclinoid Meningioma. World Neurosurg 2023; 178:e777-e790. [PMID: 37562682 DOI: 10.1016/j.wneu.2023.08.011] [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: 03/21/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE The anterior clinoid process (ACP) is surrounded by nerves and vessels that, together, constitute an intricate anatomical structure with variations that challenges the performance of individualized anterior clinoidectomy in treating lesions with different extents of invasion. In the present study, we established a 6-surface system for the ACP based on anatomical landmarks and analyzed its value in guiding ACP drilling and resection of paraclinoid meningiomas. METHODS Using the anatomical characteristics of 10 dry skull specimens, we set 9 anatomical landmarks to delineate the ACP into 6 surfaces. Guided by our 6-surface system and eggshell technique, 5 colored silicone-injected anatomical specimens were dissected via a frontotemporal craniotomy to perform anterior clinoidectomy. Next, 3 typical cases of paraclinoid meningioma were selected to determine the value of using our 6-surface system in tumor resection. RESULTS Nine points (A-H and T) were proposed to delineate the ACP surface into frontal, temporal, optic nerve, internal carotid artery, cranial nerve III, and optic strut surfaces according to the adjacent tissues. Either intradurally or extradurally, the frontal and temporal surfaces could be identified and drilled into depth, followed by skeletonization of the optic nerve, cranial nerve III, internal carotid artery, and optic strut surfaces. After the residual bone was removed, the ACP was drilled off. In surgery of paraclinoid meningiomas, our 6-surface system provided great benefit in locating the dura, nerves, and vessels, thus, increasing the safety of opening the optic canal and relaxing the oculomotor or optic nerves and allowing for individualized ACP drilling for meningioma removal. CONCLUSIONS Our 6-surface system adds much anatomical information to the classic Dolenc triangle and can help neurosurgeons, especially junior ones, to increase their understanding of the paraclinoid spatial structure and accomplish individualized surgical procedures with high safety and minimal invasiveness.
Collapse
Affiliation(s)
- Yang Wu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China; Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Xun Wu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Yun-Ze Zhang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Ying-Xi Wu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Gang Zhu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Zhi-Hong Li
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Jia-Ning Luo
- Department of Neurosurgery, West Theater General Hospital, Chengdu, Sichuan Province, China
| | - Ya-Fei Xue
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Hong-Bo Cheng
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Zhong-Qiang Lv
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Guo-Dong Gao
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China
| | - Tian-Zhi Zhao
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shaanxi Province, China.
| |
Collapse
|
2
|
Kimura T, Takeda Y, Ichi S. Modified extradural selective anterior clinoidectomy leaving the optic canal unopened for internal carotid aneurysms: A technical note. World Neurosurg X 2023; 18:100154. [PMID: 36785622 PMCID: PMC9918798 DOI: 10.1016/j.wnsx.2023.100154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/10/2023] [Indexed: 01/21/2023] Open
Abstract
Background Anterior clinoidectomy is an established procedure used to decompress the optic nerve, mobilize the internal carotid artery (ICA), or enlarge the retrocarotid space. However, its use carries the risk of optic nerve injury. In certain surgeries, such as those for internal carotid aneurysms, propose modification to the anterior clinoidectomy for enlarging the retrocarotid space, especially in operations for ICA aneurysms. Methods After the anterior clinoid process (ACP) is sufficiently exposed, the internal cancellous bone or pneumatization can be removed through a small window created at its lateral edge to reveal the compact bone of the optic canal. Since the compact bone of the inferior surface facing the ICA is absent or very thin, the ACP can be removed by drilling through the anchoring compact bone with the optic canal in direct sight. Results In 10 consecutive internal carotid aneurysm cases, the ACP was successfully removed without opening of the optic canal to enlarge the retrocarotid space. Conclusions Anterior clinoidectomy can be performed to enlarge the retrocarotid space without opening the optic canal from outside the dura.
Collapse
Affiliation(s)
- Toshikazu Kimura
- Corresponding author. Department of Neurosurgery, Japanese Red Cross Medical Center 4-1-22 Hiroo, Shibuya City, Tokyo 150-8935, Japan.
| | | | | |
Collapse
|
3
|
Tayebi Meybodi A, Mignucci-Jiménez G, Lawton MT, Liu JK, Preul MC, Sun H. Comprehensive microsurgical anatomy of the middle cranial fossa: Part I-Osseous and meningeal anatomy. Front Surg 2023; 10:1132774. [PMID: 37035561 PMCID: PMC10080110 DOI: 10.3389/fsurg.2023.1132774] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
The middle cranial fossa is one of the most complex regions in neurosurgery and otolaryngology-in fact, the practice of skull base surgery originated from the need to treat pathologies in this region. Additionally, great neurosurgeons of our present and past are remembered for their unique methods of treating diseases in the middle fossa. The following article reviews the surgical anatomy of the middle fossa. The review is divided into the anatomy of the bones, dura, vasculature, and nerves-in two parts. Emphasis is paid to their neurosurgical significance and applications in skull base surgery. Part I focuses on the bony and dural anatomy.
Collapse
Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, United States
- Correspondence: Ali Tayebi Meybodi ;
| | - Giancarlo Mignucci-Jiménez
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Michael T. Lawton
- Departments of Neurosurgery and Otolaryngology, Robert Wood Johnson Barnabas Health, Newark, NJ, United States
| | - James K. Liu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Mark C. Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Hai Sun
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, United States
- Departments of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| |
Collapse
|
4
|
Sampirisi L, D’Angelo L, Palmieri M, Pesce A, Santoro A. Extradural Clinoidectomy in Clinoidal Meningiomas: Analysis of the Surgical Technique and Evaluation of the Clinical Outcome. Tomography 2022; 8:2360-2368. [PMID: 36287796 PMCID: PMC9608954 DOI: 10.3390/tomography8050197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/13/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022] Open
Abstract
The surgical treatment of clinoidal meningiomas is currently still discussed in the literature. Different surgical approaches have been proposed and evaluated, in multiple studies, in order to improve the surgical outcomes. The aim of this study is to evaluate the advantages of extradural clinoidectomy in the context of tumor removal radicality for visual function improvement. A retrospective analysis was performed on 74 patients—of which 26 patients with clinoidal meningiomas were in group III, according to Al Mefty classification—who underwent surgery at the Policlinico Umberto I Hospital between 2000 and 2019. Further, extradural clinoidectomy was performed on 15 patients (Group A), and 11 patients underwent the pterional approach only (Group B). Additionally, visual impairment was present in all 26 patients before surgery. Next, visual function assessment was performed on all patients, both in presurgery and postsurgery. Radiological follow up was performed at 3 and 6 months, and then every 12 months. Gross Total Resection (GTR) was achieved in 13/15 (86.7%) patients who underwent clinoidectomy, and in 4/11 (36.4%) patients who did not undergo clinoidectomy. Visual function improvement was achieved in 12/15 (80%) patients who underwent clinoidectomy and in 4 of 11 (36.4%) who did not undergo clinoidectomy. According to our study, extradural clinoidectomy is the most suitable method for facilitating the gross total resection of clinoidal meningiomas. Our experience and data suggest that a higher rate of total resection and, subsequently, the best visual outcomes are achieved. Extradural drilling via the anterior clinoid process reveals a wider surgical corridor for meticulous tumor resection.
Collapse
Affiliation(s)
- Luigi Sampirisi
- Neurosurgery Division, Santa Maria Goretti University Hospital, Via Lucia Scaravelli, 04100 Latina, Italy
| | - Luca D’Angelo
- Human Neurosciences Department, Neurosurgery Division, “Sapienza” University, AOU Policlinico Umberto I, 00185 Rome, Italy
| | - Mauro Palmieri
- Human Neurosciences Department, Neurosurgery Division, “Sapienza” University, AOU Policlinico Umberto I, 00185 Rome, Italy
| | - Alessandro Pesce
- Neurosurgery Division, Santa Maria Goretti University Hospital, Via Lucia Scaravelli, 04100 Latina, Italy
- Correspondence:
| | - Antonio Santoro
- Human Neurosciences Department, Neurosurgery Division, “Sapienza” University, AOU Policlinico Umberto I, 00185 Rome, Italy
| |
Collapse
|
5
|
Lim J, Sung KS, Yoo J, Oh J, Moon JH. Endoscopic transorbital extradural anterior clinoidectomy: A stepwise surgical technique and case series study [SevEN-013]. Front Oncol 2022; 12:991065. [PMID: 36106107 PMCID: PMC9465428 DOI: 10.3389/fonc.2022.991065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background Anterior clinoidectomy is an important procedure for approaching the central skull base lesions. However, anterior clinoidectomy through the endoscopic transorbital approach (ETOA) still has limitations due to technical difficulties and the structural complexity of the anterior clinoid process (ACP). Therefore, the authors designed a stepwise surgical technique of extradural anterior clinoidectomy through the ETOA. The purpose of this study was to evaluate the feasibility of this technique. Methods Anatomical dissections were performed in 6 cadaveric specimens using a neuroendoscope and neuro-navigation system. The extradural anterior clinoidectomy through the ETOA was performed stepwise, and based on the results, this surgical technique was performed in the 7 clinical cases to evaluate its safety and efficiency. Results Endoscopic extradural anterior clinoidectomy was successfully performed in all cadaveric specimens and patients using the proposed technique. This 5-step technique enabled detachment of the lesser wing of sphenoid bone from the ACP, safe unroofing of the optic canal, and resection of the optic strut without injuring the optic nerve and internal carotid artery. Since the sequential resection of the 3 supporting roots of the ACP was accomplished safely, anterior clinoidectomy was then successfully performed in all clinical cases. Furthermore, no complications related to the anterior clinoidectomy occurred in any clinical case. Conclusion We designed a stepwise surgical technique that allows safe and efficient anterior clinoidectomy through the ETOA. Using this technique, extradural anterior clinoidectomy can be accomplished under direct endoscopic visualization with low morbidity. Since this technique is applicable to the central skull base surgery where anterior clinoidectomy is necessary, it expands the application of the ETOA.
Collapse
Affiliation(s)
- Jaejoon Lim
- Department of Neurosurgery, Bundang CHA Medical Center, CHA University College of Medicine, Seongnam, South Korea
| | - Kyoung Su Sung
- Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan, South Korea
| | - Jihwan Yoo
- Department of Neurosurgery, Brain Tumor Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jiwoong Oh
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Ju Hyung Moon
- Department of Neurosurgery, Endoscopic Skull Base Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- *Correspondence: Ju Hyung Moon,
| |
Collapse
|
6
|
Lim J, Sung KS, Kim W, Yoo J, Jung IH, Choi S, Lim SH, Roh TH, Hong CK, Moon JH. Extended endoscopic transorbital approach with superior-lateral orbital rim osteotomy: cadaveric feasibility study and clinical implications (SevEN-007). J Neurosurg 2022; 137:18-31. [PMID: 34767525 DOI: 10.3171/2021.7.jns21996] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/07/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The endoscopic transorbital approach (ETOA) has been developed, permitting a new surgical corridor. Due to the vertical limitation of the ETOA, some lesions of the anterior cranial fossa are difficult to access. The ETOA with superior-lateral orbital rim (SLOR) osteotomy can achieve surgical freedom of vertical as well as horizontal movement. The purpose of this study was to confirm the feasibility of the ETOA with SLOR osteotomy. METHODS Anatomical dissections were performed in 5 cadaveric heads with a neuroendoscope and neuronavigation system. ETOA with SLOR osteotomy was performed on one side of the head, and ETOA with lateral orbital rim (LOR) osteotomy was performed on the other side. After analysis of the results of the cadaveric study, the ETOA with SLOR osteotomy was applied in 6 clinical cases. RESULTS The horizontal and vertical movement range through ETOA with SLOR osteotomy (43.8° ± 7.49° and 36.1° ± 3.32°, respectively) was improved over ETOA with LOR osteotomy (31.8° ± 5.49° and 23.3° ± 1.34°, respectively) (p < 0.01). Surgical freedom through ETOA with SLOR osteotomy (6025.1 ± 220.1 mm3) was increased relative to ETOA with LOR osteotomy (4191.3 ± 57.2 mm3) (p < 0.01); these values are expressed as the mean ± SD. Access levels of ETOA with SLOR osteotomy were comfortable, including anterior skull base lesion and superior orbital area. The view range of the endoscope for anterior skull base lesions was increased through ETOA with SLOR osteotomy. After SLOR osteotomy, the space for moving surgical instruments and the endoscope was widened. Anterior clinoidectomy could be achieved successfully using ETOA with SLOR osteotomy. The authors performed ETOA with SLOR osteotomy in 6 cases of brain tumor. In all 6 cases, complete removal of the tumor was successfully accomplished. In the 3 cases of anterior clinoidal meningioma, anterior clinoidectomy was performed easily and safely, and manipulation of the extended dural margin and origin dura mater was possible. There was no complication related to this approach. CONCLUSIONS The authors evaluated the clinical feasibility of ETOA with SLOR osteotomy based on a cadaveric study. ETOA with SLOR osteotomy could be applied to more diverse disease groups that do not permit conventional ETOA or to cases in which surgical application is challenging. ETOA with SLOR osteotomy might serve as an opportunity to broaden the indication for the ETOA.
Collapse
Affiliation(s)
- Jaejoon Lim
- 1Department of Neurosurgery, Bundang CHA Medical Center, CHA University College of Medicine, Seongnam
| | - Kyoung Su Sung
- 2Department of Neurosurgery, Dong-A University Hospital, Dong-A University College of Medicine, Busan
| | - Woohyun Kim
- 3Department of Neurosurgery, Brain Tumor Center, Severance Hospital, Yonsei University College of Medicine, Seoul
| | - Jihwan Yoo
- 4Department of Neurosurgery, Brain Tumor Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
| | - In-Ho Jung
- 3Department of Neurosurgery, Brain Tumor Center, Severance Hospital, Yonsei University College of Medicine, Seoul
| | - Seonah Choi
- 3Department of Neurosurgery, Brain Tumor Center, Severance Hospital, Yonsei University College of Medicine, Seoul
| | - Seung Hoon Lim
- 3Department of Neurosurgery, Brain Tumor Center, Severance Hospital, Yonsei University College of Medicine, Seoul
| | - Tae Hoon Roh
- 5Department of Neurosurgery, Ajou University Hospital, Ajou University College of Medicine, Suwon; and
| | - Chang-Ki Hong
- 4Department of Neurosurgery, Brain Tumor Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
- 6Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ju Hyung Moon
- 3Department of Neurosurgery, Brain Tumor Center, Severance Hospital, Yonsei University College of Medicine, Seoul
| |
Collapse
|
7
|
Żytkowski A, Skrzat J, Mazurek A, Majos A, Radek M, Gładysz T, Clarke E, Wysiadecki G. Clinical relevance of the caroticoclinoid foramen – A case report and concise literature review. TRANSLATIONAL RESEARCH IN ANATOMY 2021. [DOI: 10.1016/j.tria.2021.100153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
8
|
Acioly MA, Hendricks BK, Cohen-Gadol A. Extradural Clinoidectomy: An Efficient Technique for Expanding the Operative Corridor Toward the Central Skull Base. World Neurosurg 2021; 145:557-566. [PMID: 33348521 DOI: 10.1016/j.wneu.2020.09.173] [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: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 10/22/2022]
Abstract
Extradural anterior clinoidectomy is an important tool for neurovascular and skull base surgery. This technique is cardinal for expanding access to the proximal carotid artery, optic nerve, sella, and the central skull base. The goal of anterior clinoidectomy is to reveal the more proximal ophthalmic and clinoidal segments of the internal carotid artery (ICA) while skeletonizing the proximal optic nerve. This maneuver expands the opticocarotid and carotid-oculomotor windows and therefore the operative corridor to the interpeduncular cisterns; both the carotid artery and optic nerve are partially untethered or liberated and can be more safely mobilized.
Collapse
Affiliation(s)
| | | | - Aaron Cohen-Gadol
- The Neurosurgical Atlas, Carmel, USA; Department of Neurosurgery, Indiana University, Indianapolis, Indiana, USA.
| |
Collapse
|
9
|
Importance of Sufficient Petrosectomy in an Anterior Petrosal Approach: Relightening of the Kawase Pyramid. World Neurosurg 2021; 153:e11-e19. [PMID: 34004357 DOI: 10.1016/j.wneu.2021.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND In 1985, Kawase published an anterior petrosal approach to expose the posterior cranial fossa and to minimize retraction of the temporal lobe. However, some neurosurgeons still have difficulty with removing tumors through an anterior petrosal approach because a complete understanding of the Kawase pyramid has not been achieved. We hypothesized that if anterior petrosectomy were performed with three-dimensional understanding of the Kawase pyramid, it would have a positive effect on extent of tumor resection. METHODS We performed a retrospective study of patients who underwent surgical treatment for meningioma through an anterior petrosal approach. Patients were divided into total resection and subtotal resection groups, and statistical differences between the groups were analyzed. To identify factors predictive of complete tumor removal, univariable and multivariable logistic regression analyses were performed. RESULTS Width and height of the drilled internal auditory canal of the total resection group were significantly larger than those of the subtotal resection group (P = 0.001, P = 0.033). The operative angle of the total resection group was significantly larger than that of the subtotal resection group (P < 0.001). Regression analyses showed only drilled internal auditory canal width to be predictive of complete tumor removal, increasing the likelihood of complete tumor removal by 2.778-fold with an increase in drilled internal auditory canal width by 1 mm (P = 0.023). CONCLUSIONS Insufficient petrosectomy during an anterior petrosal approach adversely affects the extent of tumor resection. Furthering three-dimensional understanding of the Kawase pyramid could aid in complete tumor resection and better outcomes without causing damage to the surrounding organs.
Collapse
|
10
|
Arachnoid and dural reflections. HANDBOOK OF CLINICAL NEUROLOGY 2021; 169:17-54. [PMID: 32553288 DOI: 10.1016/b978-0-12-804280-9.00002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
The dura mater is the major gateway for accessing most extra-axial lesions and all intra-axial lesions of the central nervous system. It provides a protective barrier against external trauma, infections, and the spread of malignant cells. Knowledge of the anatomical details of dural reflections around various corners of the skull bases provides the neurosurgeon with confidence during transdural approaches. Such knowledge is indispensable for protection of neurovascular structures in the vicinity of these dural reflections. The same concept is applicable to arachnoid folds and reflections during intradural excursions to expose intra- and extra-axial lesions of the brain. Without a detailed understanding of arachnoid membranes and cisterns, the neurosurgeon cannot confidently navigate the deep corridors of the skull base while safely protecting neurovascular structures. This chapter covers the surgical anatomy of dural and arachnoid reflections applicable to microneurosurgical approaches to various regions of the skull base.
Collapse
|
11
|
Gallardo FC, Bustamante JL, Martin C, Targa Garcia AA, Feldman SE, Pastor F, Orellana MC, Rubino PA, Quilis Quesada V. Intra- and extradural anterior clinoidectomy: anatomy review and surgical technique step by step. Surg Radiol Anat 2021; 43:1291-1303. [PMID: 33495868 DOI: 10.1007/s00276-021-02681-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/07/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE The complex relations of the paraclinoid area make the surgical management of the pathology of this region a challenge. The anterior clinoid process (ACP) is an anatomical landmark that hinders the visualization and manipulation of the surrounding neurovascular structures, hence in certain surgical interventions might be necessary to remove it. We reviewed the anatomical relationships that involve the paraclinoid area and detailed the step-by-step techniques of intra and extradural clinoidectomy in cadaveric specimens. MATERIALS AND METHODS A literature review was done describing the most relevant anatomic relationships regarding the anterior clinoid process. Extradural and intradural clinoidectomy techniques were performed in six dry bone heads and in ten previously injected cadaverous specimens with colored latex (Sanan et al. in Neurosurgery 45:1267-1274, 1999) and each step of the procedure was recorded using photographic material. Finally, an analysis of the anatomical exposure achieved in each of the techniques used was performed. RESULTS The main advantage of the intradural clinoidectomy technique is the direct visualization of the neurovascular structures adjacent to the ACP when drilling, at the same time, opening the Sylvian fissure will allow the direct visualization of the ACP variants. The main advantage offered by the extradural technique is that the dura protects adjacent eloquent structures while drilling. Among the disadvantages, it is noted that the same dura that would protect the underlying structures also prevents the direct visualization of these neurovascular structures adjacent to the ACP. CONCLUSION We reviewed the anatomy of the paraclinoid area and made a step-by-step description of the technique of the anterior clinoidectomy in its intra- and extradural variants in cadaveric preparations for a better understanding.
Collapse
Affiliation(s)
| | - Jorge Luis Bustamante
- Department of Neurosurgery, Hospital de Alta Complejidad El Cruce, Buenos Aires, Argentina
| | - Clara Martin
- Department of Neurosurgery, Hospital de Alta Complejidad El Cruce, Buenos Aires, Argentina
| | | | | | - Felix Pastor
- Department of Neurosurgery, Hospital Clínic Universitari de València, Valencia, Spain
| | | | - Pablo Augusto Rubino
- Department of Neurosurgery, Hospital de Alta Complejidad El Cruce, Buenos Aires, Argentina
| | - Vicent Quilis Quesada
- Department of Neurosurgery, Hospital Clínic Universitari de València, Valencia, Spain.,College of Medicine and Science, Mayo Clinic, Rochester, USA.,Department of Human Anatomy and Embryology, Faculty of Medicine, University of Valencia, Valencia, Spain
| |
Collapse
|
12
|
Alejandro SA, Carrasco-Hernández JP, da Costa MDS, Ferreira DS, Lima JVF, de Amorim BL, Paz-Archila JA, Chaddad-Neto F. Anterior Clinoidectomy: Intradural Step-by-Step En Bloc Removal Technique. World Neurosurg 2020; 146:217-231. [PMID: 33248309 DOI: 10.1016/j.wneu.2020.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Anterior clinoidectomy is an important and essential skill for skull base and cerebrovascular neurosurgeons. We present a 1-piece intradural anterior clinoidectomy, providing a step-by-step description of the technique, independently of anatomic variations. METHODS Between 2014 and 2020, 128 patients (119 women and 9 men; average age, 54.6 years) underwent intradural anterior clinoidectomy during microsurgical clipping of carotid-ophthalmic aneurysms. RESULTS The anterior clinoid process continues medially with the planum sphenoidale, over the optic nerve, laterally with the lesser wing of the sphenoid bone, and inferiorly with the optic strut, which is always found anteriorly to the clinoid segment of the internal carotid artery, and separates the optic canal from the superior orbital fissure. The proposed anterior clinoidectomy followed, one after the other, these 3 fixation points for the detachment of the anterior clinoid process. The main indication for intradural anterior clinoidectomy was the management of vascular lesions around paraclinoid (clinoidal and ophthalmic) segments of the internal carotid artery. Complications of the procedure included injury to the internal carotid artery or the ophthalmic artery, thermal damage to the optic nerve, and invasion of the sphenoid sinus or a pneumatized anterior clinoid process, which could lead to postoperative cerebrospinal fluid leakage. CONCLUSIONS The anterior clinoidectomy technique described here minimizes the drilling surface for detachment of the anterior clinoid process and reduces operative time as well as the amount of bone dust produced by drilling. It also precisely delineates the localization of the optic strut, preventing carotid or optic nerve damage.
Collapse
Affiliation(s)
| | | | | | - Danilo Santos Ferreira
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, São Paulo, Brazil
| | | | - Bruno Loof de Amorim
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, São Paulo, Brazil
| | | | - Feres Chaddad-Neto
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, São Paulo, Brazil; Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| |
Collapse
|
13
|
Engin Ӧ, Adriaensen GFJPM, Hoefnagels FWA, Saeed P. A systematic review of the surgical anatomy of the orbital apex. Surg Radiol Anat 2020; 43:169-178. [PMID: 33128648 PMCID: PMC7843489 DOI: 10.1007/s00276-020-02573-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 09/12/2020] [Indexed: 02/07/2023]
Abstract
Purpose The orbital apex is the narrowest part of the orbit, housing the link between the intracranial cavity and orbit. Knowledge of orbital apex anatomy is crucial to selecting a surgical approach and reducing the risk of complications. Our purpose is to summarize current knowledge on surgical anatomy and attempt to reach a consensus on definition of the orbital apex.
Methods The online databases of Embase, the Cochrane library, Web of Science and PubMed (MEDLINE) were queried in a comprehensive bibliographic search on the (surgical) anatomy of the orbital apex and consisted of a combination of two subjects, using indexed terms and free text: “Orbital Apex” and “Orbital Anatomy.” Results A total of 114 relevant papers were included in this review. Numerous anatomical variations are described in the literature. Variations of the optic canal include duplication (0.64%) and keyhole anomaly (2.65%). Variations in pneumatization of the anterior clinoid process were unilateral in almost 10%, bilateral in 9%, and normal in 72%. A rare variant of the superior orbital fissure (SOF) is Warwick’s foramen, which appears as if the lowest portion of the SOF was separated from the main fissure by a transverse bony bridge. Conclusion The definition of the orbital apex varies in the literature, and further research would most likely identify additional variations. A universal definition reporting these variations and pathology and imaging findings is essential for determining the optimal surgical approach to the orbital apex. Electronic supplementary material The online version of this article (10.1007/s00276-020-02573-w) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Ӧ Engin
- Orbital Center, Ophthalmology Department, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.
| | - G F J P M Adriaensen
- Orbital Center, Ophthalmology Department, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
- Otorhinolaryngology Department, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - F W A Hoefnagels
- Orbital Center, Ophthalmology Department, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
- Neurosurgery Department, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - P Saeed
- Orbital Center, Ophthalmology Department, Amsterdam UMC, location AMC, Amsterdam, The Netherlands.
| |
Collapse
|
14
|
Chaddad-Neto F, da Costa MDS, Santos B, Caramanti RL, Costa BL, Doria-Netto HL, Figueiredo EG. Reproducibility of a new classification of the anterior clinoid process of the sphenoid bone. Surg Neurol Int 2020; 11:281. [PMID: 33033643 PMCID: PMC7538961 DOI: 10.25259/sni_133_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 07/08/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Pneumatization of the anterior clinoid process (ACP) affects paraclinoid region surgery, this anatomical variation occurs in 6.6–27.7% of individuals, making its preoperative recognition essential given the need for correction based on the anatomy of the pneumatized process. This study was conducted to evaluate the reproducibility of an optic strut-based ACP pneumatization classification by presenting radiological examinations to a group of surgeons. Methods: Thirty cranial computer tomography (CT) scans performed from 2013 to 2014 were selected for analysis by neurosurgery residents and neurosurgeons. The evaluators received Google Forms with questionnaires on each scan, DICOM files to be manipulated in the Horos software for multiplanar reconstruction, and a collection of slides demonstrating the steps for classifying each type of ACP pneumatization. Interobserver agreement was calculated by the Fleiss kappa test. Results: Thirty CT scans were analyzed by 37 evaluators, of whom 20 were neurosurgery residents and 17 were neurosurgeons. The overall reproducibility of the ACP pneumatization classification showed a Fleiss kappa index of 0.49 (95% confidence interval: 0.49–0.50). The interobserver agreement indices for the residents and neurosurgeons were 0.52 (0.51–0.53) and 0.49 (0.48–0.50), respectively, and the difference was statistically significant (P < 0.00001). Conclusion: The optic strut-based classification of ACP pneumatization showed acceptable concordance. Minor differences were observed in the agreement between the residents and neurosurgeons. These differences could be explained by the residents’ presumably higher familiarity with multiplanar reconstruction software.
Collapse
Affiliation(s)
| | | | - Bruno Santos
- Department of Neurosurgery, Universidade Federal de São Paulo
| | | | - Bruno Lourenco Costa
- Department of Neurosurgery, Centro Hospitalar Tondela-Viseu, EPE, Viseu, Portugal
| | | | | |
Collapse
|
15
|
Graillon T, Regis J, Barlier A, Brue T, Dufour H, Buchfelder M. Parasellar Meningiomas. Neuroendocrinology 2020; 110:780-796. [PMID: 32492684 DOI: 10.1159/000509090] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/02/2020] [Indexed: 11/19/2022]
Abstract
Parasellar spaces remain particularly singular, comprising the most important neurovascular structures such as the internal carotid artery and optic, oculomotor, and trigeminal nerves. Meningiomas are one of the most frequent tumors arising from parasellar spaces. In this location, meningiomas remain mostly benign tumors with WHO grade I and a meningothelial subtype. Progestin intake should be investigated and leads mostly to conservative strategies. In the case of benign nonsymptomatic tumors, observation should be proposed. Tumor growth will lead to the proposition of surgery or radiosurgery. In the case of an uncertain diagnosis and an aggressive pattern, a precise diagnosis is required. For cavernous sinus and Meckel's cave lesions, complete removal is rarely considered, leading to the proposition of an endoscopic endonasal or transcranial biopsy. Optic nerve decompression could also be proposed via these approaches. A case-by-case discussion about the best approach is recommended. A transcranial approach remains necessary for tumor removal in most cases. Vascular injury could lead to severe complications. Cerebrospinal fluid leakage, meningitis, venous sacrifice, visual impairment, and cranial nerve palsies are more frequent complications. Pituitary dysfunctions are rare in preoperative assessment and in postoperative follow-up but should be assessed in the case of meningiomas located close to the pituitary axis. Long-term follow-up is required given the frequent incomplete tumor removal and the risk of delayed recurrence. Radiosurgery is relevant for small and well-limited meningiomas or intra-cavernous sinus postoperative residue, whereas radiation therapy and proton beam therapy are indicated for large, extended, nonoperable meningiomas. The place of the peptide receptor radionuclide therapyneeds to be defined. Targeted therapy should be considered in rare, recurrent, and aggressive parasellar meningiomas.
Collapse
Affiliation(s)
- Thomas Graillon
- Neurosurgery Department, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, CHU Timone, Marseille, France,
- Aix-Marseille University, INSERM, MMG, Marseille, France,
| | - Jean Regis
- Gamma Knife Unit, Functional and Stereotactic Department, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, CHU Timone, Marseille, France
| | - Anne Barlier
- Aix-Marseille University, INSERM, MMG, Marseille, France
- Molecular Biology Department, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, CHU Timone, Marseille, France
| | - Thierry Brue
- Aix-Marseille University, INSERM, MMG, Marseille, France
- Endocrinology Department, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, CHU Conception, Marseille, France
| | - Henry Dufour
- Neurosurgery Department, Aix-Marseille University, Assistance Publique-Hôpitaux de Marseille, CHU Timone, Marseille, France
- Aix-Marseille University, INSERM, MMG, Marseille, France
| | - Michael Buchfelder
- Department of Neurosurgery, University Hospital of Erlangen, Erlangen, Germany
| |
Collapse
|
16
|
Saraceno G, Agosti E, Qiu J, Buffoli B, Ferrari M, Raffetti E, Belotti F, Ravanelli M, Mattavelli D, Schreiber A, Hirtler L, Rodella LF, Maroldi R, Nicolai P, Gentili F, Kucharczyk W, Fontanella MM, Doglietto F. Quantitative Anatomical Comparison of Anterior, Anterolateral and Lateral, Microsurgical and Endoscopic Approaches to the Middle Cranial Fossa. World Neurosurg 2019; 134:e682-e730. [PMID: 31731015 DOI: 10.1016/j.wneu.2019.10.178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 10/27/2019] [Accepted: 10/28/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To quantitatively compare different microsurgical and endoscopic approaches to the middle cranial fossa in a preclinical setting with a novel, computer-based research method. METHODS Different approaches were performed bilaterally in 5 head and neck specimens that underwent high-resolution computed tomography scans: 5 transcranial anterolateral (supraorbital, mini-pterional, pterional, pterional-transzygomatic, fronto-temporal-orbito-zygomatic) without and with anterior clinoidectomy; 2 transcranial lateral (subtemporal and subtemporal-transzygomatic); 2 endoscopic transnasal (transpterygoid, transpterygoid to infratemporal fossa); 2 endoscopic transorbital (superior eyelid and inferolateral), and endoscopic transmaxillary. A dedicated navigation system was used to quantify surgical working volumes and exposure of different areas of the middle cranial fossa (ApproachViewer, part of GTx-Eyes II, University Health Network, Toronto, Canada). Statistical analysis was performed using a mixed linear model with bootstrap resampling. RESULTS Endoscopic transnasal and fronto-temporal-orbito-zygomatic approaches with anterior clinoidectomy showed the largest surgical volumes. Endoscopic approaches allowed a wider exposure of medial anatomical surfaces (e.g., the petrous apex) compared with transcranial ones. Transcranial approaches with larger craniotomies allowed the widest exposure of superomedial anatomical structures (e.g., roof of cavernous sinus). The resection of the zygomatic arch allowed exposure of more medial surfaces with an inferior to superior trajectory. CONCLUSIONS This study implemented a novel neuronavigation-based research method to quantitatively compare different approaches to the middle cranial fossa; its results might guide, after consideration of clinical implications, the choice of the neurosurgical approach to different areas of this complex skull base region.
Collapse
Affiliation(s)
- Giorgio Saraceno
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Edoardo Agosti
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Jimmy Qiu
- TECHNA Institute, University Health Network, Toronto, Ontario, Canada
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Ferrari
- Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Elena Raffetti
- Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Francesco Belotti
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ravanelli
- Radiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Davide Mattavelli
- Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alberto Schreiber
- Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Luigi F Rodella
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Radiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Otorhinolaryngology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Fred Gentili
- Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Walter Kucharczyk
- Division of Neuroradiology, Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Marco M Fontanella
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Doglietto
- Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
| |
Collapse
|
17
|
Tayebi Meybodi A, Lawton MT, Yousef S, Guo X, González Sánchez JJ, Tabani H, García S, Burkhardt JK, Benet A. Anterior clinoidectomy using an extradural and intradural 2-step hybrid technique. J Neurosurg 2019; 130:238-247. [PMID: 29473783 DOI: 10.3171/2017.8.jns171522] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/28/2017] [Indexed: 11/06/2022]
Abstract
In Brief: The authors found a practical intraoperative landmark to localize the optic strut during anterior clinoidectomy and used it as the basis for performing anterior clinoidectomy in two steps: extradural phase and intradural phase. This anatomically based technique can increase the safety of anterior clinoidectomy by providing easily identifiable landmarks and reducing intradural bone drilling, which could put the adjacent neurovauscular structures at risk.
Collapse
Affiliation(s)
- Ali Tayebi Meybodi
- 1Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael T Lawton
- 1Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Sonia Yousef
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and
| | - Xiaoming Guo
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and.,3Department of Neurosurgery, First Affiliated Hospital of Chinese PLA General Hospital, Beijing, People's Republic of China
| | | | - Halima Tabani
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and
| | - Sergio García
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and
| | - Jan-Karl Burkhardt
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and
| | - Arnau Benet
- 1Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| |
Collapse
|
18
|
Xiao L, Xie S, Tang B, Hu J, Hong T. Endoscopic endonasal anterior clinoidectomy: surgical anatomy, technique nuance, and case series. J Neurosurg 2019; 133:451-461. [PMID: 31277066 DOI: 10.3171/2019.4.jns183213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 04/08/2019] [Indexed: 11/06/2022]
Abstract
Advances in endoscopic technique allow for resection of the anterior clinoid process (ACP) via an endoscopic endonasal approach. The authors discuss the endoscopic endonasal anterior clinoidectomy (EEAC) and demonstrate the relevant surgical anatomy and technical nuances. The approach was simulated in 6 cadaveric heads. From a technical point of view, the lateral optic carotid recess was used as the landmark in the proposed technique. The superomedial, superolateral, and inferior vertices of this recess are the main operative points. The EEAC approach was achieved by disconnecting the ACP tip from the base by drilling the 3 vertices. The proposed approach was successfully performed in all cadaveric specimens. Then, in a case series involving 6 patients in whom the EEAC approach was used, there were no vascular injuries; 2 patients had postoperative oculomotor nerve palsy, which improved in one and resolved in the other by 1 month.The EEAC approach for tumors and vascular lesions in the parasellar region is technically feasible. The surgical corridor is increased by ACP resection, although to a lesser extent than the transcranial anterior clinoidectomy. Based on the authors' initial anatomical and surgical results, resection of the ACP via the endonasal endoscopic approach is a novel technique worth exploring in suitable cases.
Collapse
|
19
|
Cherian I, Kasper EM, Agarwal A. The Orbitomeningeal Band as a Way to Bloodless Transcavernous Dissection and Anterior Clinoidectomy. Asian J Neurosurg 2018; 13:943-945. [PMID: 30283589 PMCID: PMC6159013 DOI: 10.4103/ajns.ajns_198_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The meningo-orbital band (MOB) is a dural fold which runs along the lateral border of the superior orbital fissure and contains few small dural veins and the orbitomeningeal artery. MOB detachment is relatively easy to understand step-wise procedure, provides a wider exposure, and better orientation thus facilitating relatively easy approach to paraclinoid and cavernous sinus region. The present microsurgical technique helps to preserve the true cavernous membrane and thereby providing almost bloodless dissection of the cavernous sinus. The same technique can be used to uncover the anterior clinoid process laterally, posteriorly, superiorly, and also in the inferolateral region thereby decreasing the risk and time of clinoidectomy.
Collapse
Affiliation(s)
- Iype Cherian
- Department of Neurosurgery, College of Medical sciences, Bharatpur, Chitwan, Nepal
| | - Ekkehard M Kasper
- Department of Neurosurgery, Harvard Medical School and Director of Neurosurgical Oncology at BIDMC, Boston/MA, USA
| | - Amit Agarwal
- Department of Neurosurgery, Narayana Medical College and Hospital, Chintareddypalem, Nellore, Andhra Pradesh, India
| |
Collapse
|
20
|
Salgado López L, Muñoz Hernández F, Asencio Cortés C, Tresserras Ribó P, Álvarez Holzapfel MJ, Molet Teixidó J. Extradural anterior clinoidectomy in the management of parasellar meningiomas: Analysis of 13 years of experience and literature review. Neurocirugia (Astur) 2018; 29:225-232. [PMID: 29753644 DOI: 10.1016/j.neucir.2018.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 02/23/2018] [Accepted: 04/09/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND AND AIM The extradural anterior clinoidectomy (EAC) is a key microsurgical technique that facilitates the resection of tumors located in the parasellar region. There is currently no consensus regarding the execution of the procedure via extradural or intradural nor scientific evidence that supports its routine use. The purpose of this article is to expose our experience in performing EAC as part of the management of the parasellar meningiomas. MATERIALS AND METHODS A retrospective analysis of the EAC for parasellar meningioma resection performed in our center between 2003 and 2015 was done. A total of 53 patients were recorded. We analized our series focusing on visual outcomes, resection rates and complications. Through an extensive bibliographic research, we discussed the advantages and disadvantages of the EAC, technical considerations, comparison with the intradural clinoidectomy and its visual impact. RESULTS The most frequent tumors were anterior clinoidal meningiomas (33.9%). The most common initial symptoms were decreased visual acuity (45.3%) and headache (22.6%). A gross total resection was achieved in 67.9%, being subtotal in the remaining 32.1%. Regarding the visual deficits 67.9% of the patients presented clinical stability, 22.6% improvement and 9.4% worsening. The degree of tumor resection did not significantly influence post-surgical visual outcomes, either visual acuity (P=.71) or campimetric alterations (P=.53). 24.5% of the patients experienced iiinerve transient paresis and 1.9% permanent. The postoperative cerebrospinal fluid leak rate was 3.8%. Mortality rate was 0%. The mean follow-up was 82.3 months. CONCLUSIONS In our experience, EAC is a safe technique that facilitates the resection of the meningiomas located in the parasellar area, helps to achieve early tumor devascularization, reduces the need for retraction of the cerebral parenchyma and could play a positive role in the preservation of visual function and the appearance of tumor recurrences in the anterior clinoid process (ACP).
Collapse
Affiliation(s)
- Laura Salgado López
- Departamento de Neurocirugía, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, España.
| | - Fernando Muñoz Hernández
- Departamento de Neurocirugía, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, España
| | - Carlos Asencio Cortés
- Departamento de Neurocirugía, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, España
| | - Pere Tresserras Ribó
- Departamento de Neurocirugía, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, España
| | | | - Joan Molet Teixidó
- Departamento de Neurocirugía, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, España
| |
Collapse
|
21
|
Calculation of an Optic Nerve Injury Risk Profile Before Sphenoid Sinus Surgery. J Craniofac Surg 2018; 28:e75-e78. [PMID: 27906848 DOI: 10.1097/scs.0000000000003239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Our objective was to analyze variations in the optic nerve (ON) course and surrounding structures in an effort to construct an optic nerve injury risk profile before endoscopic intranasal sphenoidal, or endoscopic endonasal transphenoidal, skull-base surgery, and eventually to construct and formulate a common classification by combining the known classes. The authors used computed tomography (CT) toward this end. METHODS The authors retrospectively reviewed 200 consecutive CT scans (400 sides) of the paranasal sinuses. The pneumatization of the anterior clinoid process, the relationships of the ONs to the sphenoidal sinuses, and ON dehiscence were evaluated. The authors then created a formula by which risk profiles can be constructed for patients for whom sphenoid or parasellar surgery is planned. RESULTS Pneumatization of the anterior clinoid process was evident in 28.25%. Dehiscence of the bony wall of the ON was evident in 9.5%. The ON course lay adjacent to the sphenoidal sinus, causing sinus wall indentation, in 23%. Cumulative optic nerve injury risk scoring showed that, radiologically, surgery on 8.5% and 1.5% of sphenoid sinuses described here carried severe or critical risk of ON injury, respectively. CONCLUSIONS Head-and-neck surgeons and neurosurgeons should be aware of variations in ON course. The authors composed an optic nerve injury risk classification category based on the sum of individual weights of each of these classes. Reductions in ON injuries require careful evaluation of potential variant anatomies. Preoperative CT scans must be meticulously reviewed to avoid ON injury.
Collapse
|
22
|
Matsuo S, Komune N, Tsuchimochi R, Kai Y, Matsumoto K, Haga S, Inoue T. The Microsurgical Relationships between Internal Carotid-Posterior Communicating Artery Aneurysms and the Skull Base. J Neurol Surg B Skull Base 2017; 79:427-436. [PMID: 30210969 DOI: 10.1055/s-0037-1615804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 11/19/2017] [Indexed: 10/18/2022] Open
Abstract
Objective This study aimed to review the anatomical and clinical characteristics of internal carotid-posterior communicating artery (IC-PC) aneurysms, especially those located close to the skull base. Methods The microsurgical anatomy around the posterior communicating artery (PComA) was examined in a dry skull and five formalin-fixed human cadaveric heads. The clinical characteristics of 37 patients with 39 IC-PC aneurysms, who were treated microsurgically between April 2008 and July 2016, were retrospectively reviewed. Results The anterior clinoid process (ACP), as well as the anterior petroclinoidal dural fold (APF), which forms part of the oculomotor triangle, are closely related to the origin of the PComA. Among the 39 IC-PC aneurysms, anterior clinoidectomy was performed on 4 (10.3%) and a partial resection of the APF was performed on 2 (5.1%). Both of these aneurysms projected inferior to the tentorium, or at least part of the aneurysm's dome was inferior to the tentorium. Conclusion Proximally located IC-PC aneurysms have an especially close relationship with the ACP and APF. We should be familiar with the anatomical relationship between IC-PC aneurysms and the structures of the skull base to avoid hazardous complications.
Collapse
Affiliation(s)
- Satoshi Matsuo
- Department of Neurosurgery, Kyushu Central Hospital, Fukuoka, Japan.,Department of Neurosurgery, Clinical Research Institute, Kyushu Medical Center, National Hospital Organization, Fukuoka, Japan
| | - Noritaka Komune
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Yasutoshi Kai
- Department of Neurosurgery, Iizuka Hospital, Fukuoka, Japan
| | - Kenichi Matsumoto
- Department of Neurosurgery, Saga Medical Center Koseikan, Saga, Japan
| | - Sei Haga
- Department of Neurosurgery, Kyushu Rosai Hospital, Fukuoka, Japan
| | - Takuya Inoue
- Department of Neurosurgery, Kyushu Central Hospital, Fukuoka, Japan
| |
Collapse
|
23
|
Okonogi S, Kondo K, Harada N, Masuda H, Nemoto M, Sugo N. Operative simulation of anterior clinoidectomy using a rapid prototyping model molded by a three-dimensional printer. Acta Neurochir (Wien) 2017; 159:1619-1626. [PMID: 28508160 DOI: 10.1007/s00701-017-3202-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/24/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND As the anatomical three-dimensional (3D) positional relationship around the anterior clinoid process (ACP) is complex, experience of many surgeries is necessary to understand anterior clinoidectomy (AC). We prepared a 3D synthetic image from computed tomographic angiography (CTA) and magnetic resonance imaging (MRI) data and a rapid prototyping (RP) model from the imaging data using a 3D printer. The objective of this study was to evaluate anatomical reproduction of the 3D synthetic image and intraosseous region after AC in the RP model. In addition, the usefulness of the RP model for operative simulation was investigated. METHODS The subjects were 51 patients who were examined by CTA and MRI before surgery. The size of the ACP, thickness and length of the optic nerve and artery, and intraosseous length after AC were measured in the 3D synthetic image and RP model, and reproducibility in the RP model was evaluated. In addition, 10 neurosurgeons performed AC in the completed RP models to investigate their usefulness for operative simulation. RESULTS The RP model reproduced the region in the vicinity of the ACP in the 3D synthetic image, including the intraosseous region, at a high accuracy. In addition, drilling of the RP model was a useful operative simulation method of AC. CONCLUSIONS The RP model of the vicinity of ACP, prepared using a 3D printer, showed favorable anatomical reproducibility, including reproduction of the intraosseous region. In addition, it was concluded that this RP model is useful as a surgical education tool for drilling.
Collapse
Affiliation(s)
- Shinichi Okonogi
- Department of Neurosurgery (Omori), Toho University Graduate School of Medicine, 6-11-1, Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Kosuke Kondo
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Naoyuki Harada
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Hiroyuki Masuda
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Masaaki Nemoto
- Department of Neurosurgery (Omori), School of Medicine, Faculty of Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Nobuo Sugo
- Department of Neurosurgery (Omori), Toho University Graduate School of Medicine, 6-11-1, Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan
| |
Collapse
|
24
|
da Costa MDS, de Oliveira Santos BF, de Araujo Paz D, Rodrigues TP, Abdala N, Centeno RS, Cavalheiro S, Lawton MT, Chaddad-Neto F. Anatomical Variations of the Anterior Clinoid Process. Oper Neurosurg (Hagerstown) 2016; 12:289-297. [DOI: 10.1227/neu.0000000000001138] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 10/04/2015] [Indexed: 12/14/2022] Open
|
25
|
Lee JS, Scerrati A, Zhang J, Ammirati M. Quantitative analysis of surgical exposure and surgical freedom to the anterosuperior pons: comparison of pterional transtentorial, orbitozygomatic, and anterior petrosal approaches. Neurosurg Rev 2016; 39:599-605. [PMID: 27075862 DOI: 10.1007/s10143-016-0710-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 03/06/2016] [Indexed: 01/02/2023]
Abstract
Surgical approaches to the pons lump together different areas of the pons, such as the anterosuperior and the anteroinferior pons. These areas are topographically different, and different approaches may be best suited for one or the other area. We evaluated the exposure of the anterosuperior pons using different surgical approaches. We quantify the surgical exposure and surgical freedom to the anterosuperior pons afforded by the pterional transtentorial (PT), the orbitozygomatic with anterior clinoidectomy (OZ), and the anterior petrosal (AP) approaches. Five embalmed cadaver heads were used. The three approaches were executed on each side, for a total of 30 approaches. The area of maximal exposure of the anterosuperior pons was measured with the aid of neuronavigation. We also evaluated the feasible angles of approach in the vertical and horizontal planes. We were able to successfully expose the anterosuperior pons using all the selected approaches. In the PT and OZ approaches, mobilization of the sphenoparietal sinus can prevent over-retraction of the temporal bridging veins, while use of the endoscope can help in preserving the integrity of the fourth nerve while cutting the tentorium. The mean exposure area was largest for the AP and smallest for the PT; the surgical freedom was similar among all the approaches. However, there was no statistically significant difference among all the approaches in the exposure area or in the surgical freedom. There is no significant difference among the three evaluated approaches in exposure of the anterosuperior pons.
Collapse
Affiliation(s)
- Jung-Shun Lee
- Section of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Dardinger Microneurosurgical Skull Base Laboratory, Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Alba Scerrati
- Institute of Neurosurgery, Catholic University of Rome, Rome, Italy.,Dardinger Microneurosurgical Skull Base Laboratory, Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Jun Zhang
- Department of Radiology and Wright Center of Innovation in Biomedical Imaging, Wexner Medical Center, The Ohio State University, N1025 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Mario Ammirati
- Dardinger Microneurosurgical Skull Base Laboratory, Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.
| |
Collapse
|