1
|
Peto I, Pressman E, Piper K, Flores-Milan G, Ryan C, Vakharia K, van Loveren H, Agazzi S. Application of Topographical Anatomy of the Trochlear Nerve in Transtentorial Approaches: An Anatomic Study. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01309. [PMID: 39207147 DOI: 10.1227/ons.0000000000001346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 07/15/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Transection of the free edge of tentorium (FET) might be necessary when approaching cavernous sinus lesions, clip placement in certain posterior communicating artery aneurysms, or during transpetrosal and retrosigmoid transtentorial approaches. No anatomic study has investigated the relationship of the trochlear and oculomotor nerve and FET in an attempt to identify a safe zone for such maneuver. METHODS Ten embalmed specimens (20 sides) were studied and the following morphometric measurements were taken using digital microcalipers: trochlear (TP) to oculomotor porus (OP), length of the intratentorial segment of cranial nerve (CN) IV, nerve free FET, and distance along the oculomotor (CN III) from its OP to CN III/trochlear (CN IV) crossing and angle between the long-axis petrous ridge and TP (petrotrochlear angle). RESULTS The CN IV pierced the deep layer of the FET in all cases at a mean distance 8.11 mm (4.43-11.33) posterior to the OP, measured along the FET. CN IV continued within the tentorial edge for a mean of 6.17 mm (3.18-11.33) before entering the cavernous sinus at a mean distance of 1.9 mm (0-5.46 mm) from the posterior-most aspect of the OP. A nerve-free portion of FET was 1.93 mm (mean) (0-5.46). No nerve-free FET segment (<1 mm) was observed in 4 sides (20%), and a nerve-free FET segment <2.00 mm was seen in 55% of cases. The mean distance from OP to the CN III/IV crossing was 10.17 mm (1.00-15.57). The mean petrotrochlear angle was 164.49° (140.01-183.85), and >175° in 4 specimens (20%). CONCLUSION Our data confirm presence of the intratentorial segment of CN IV. Transection of the FET carries the lowest risk of CN IV injury if performed < 2 mm or >10 mm posterior to the OP, or posterior to intersection of the FET and a virtual extension of a petrous ridge.
Collapse
Affiliation(s)
- Ivo Peto
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | | | | | | | | | | | | | | |
Collapse
|
2
|
Jha DK, Agrawal M, Gosal JS, Janu V, Agrawal DK, Sharma RK, Garg M, Ghatak S, Elhence P, Bhatia PK. Manual Instruments as an Alternative to Drilling for Bony Exposure in Skull Base Surgery: Concept and Technique. J Neurol Surg B Skull Base 2024; 85:212-220. [PMID: 38449585 PMCID: PMC10914465 DOI: 10.1055/a-2031-3647] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/05/2023] [Indexed: 02/12/2023] Open
Abstract
Background Drilling in neurosurgery is an integral part of surgical exposure, especially in skull base approaches and craniovertebral junction (CVJ) surgeries. Most of such drillings are done in close proximity to the neurovascular structures in skull base surgeries and cervical-medullary junction or facet/pedicle in CVJ surgeries. Reluctance to drilling among young neurosurgeons is due to less hands-on experience during training and also, in the early part of the career, due to fear of injury to neurovascular structures. Methods Five commonest bone removals for skull base region and CVJ surgeries that can be safely done using manual instruments were identified based on experiences of senior authors. The authors highlight key technical nuances to widen surgical corridors using manual instruments safely for skull base surgical approaches. Results Basic neuroanatomical concepts and basic physics help in using manual instruments safely for bone removals in various skull base surgical approaches. Conclusions Manual instruments may be used for bone removals in selected skull base surgical approaches, which help young neurosurgeons to perform these surgeries in limited-resource settings.
Collapse
Affiliation(s)
- Deepak K. Jha
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Mohit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Jaskaran Singh Gosal
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Vikas Janu
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Dhruv K. Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Raghvendra K. Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Mayank Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Surajit Ghatak
- Department of Anatomy, All India Institute of Medical Sciences, Jodhpur, India
| | - Poonam Elhence
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Pradeep K. Bhatia
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, India
| |
Collapse
|
3
|
Rai HIS, Kayssi AR, Krisht A. Pretemporal Transcavernous Approach to Basilar Tip Aneurysms: Operative Technique and Surgical Nuances: 3-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 26:226-227. [PMID: 37878476 DOI: 10.1227/ons.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 08/31/2023] [Indexed: 10/27/2023] Open
Abstract
INDICATIONS CORRIDORS AND LIMITS OF EXPOSURE This approach provides a 360° view of the anterior upper third of posterior fossa which can tackle any kind of complex basilar aneurysm. It combines the benefits of both pterional/orbitozygomatic and subtemporal approaches. ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT Computed tomography angiography revealed a low-lying basilar apex, so a full transcavernous approach was used. Electroencephalogram, somatosensory evoked potentials, and brainstem auditory evoked response are essential modalities to monitor during temporary clipping. ESSENTIAL STEPS OF THE PROCEDURE Anterior clinoidectomy, dissection of cavernous sinus, and posterior clinoidectomy to expose the perforator-free zone of basilar artery proximal to the superior cerebellar artery are essential steps described in detail in the video. Analyzing the perforator anatomy around the aneurysm before putting a clip is utmost essential. PITFALLS/AVOIDANCE OF COMPLICATIONS Clipping a basilar aneurysm using this approach requires a neurosurgeon to have a sound knowledge of the neuroanatomy as well as a skilled handset for performing clinoidectomy and cavernous sinus dissection to avoid neurovascular injury. VARIANTS AND INDICATIONS FOR THEIR USE Pterional/orbitozygomatic (for high riding bifurcation), subtemporal (low riding bifurcation), and endovascular therapy (small aneurysm with narrow neck) are other options used for these aneurysms.
Collapse
|
4
|
Almeida JP, Finger G, Weber MD, Damante MA, Wu KC, Walz P, Leonard JR, Carrau RL, Prevedello DM. Intradural Pituitary Hemitransposition: Technical Note and Case Series Illustration. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-01003. [PMID: 38132563 DOI: 10.1227/ons.0000000000001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/06/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Lesions located in the retrosellar region, interpeduncular cistern, and petroclival region are among the most difficult to access in neurosurgery. Transcranial approaches are useful; however, the large distance between the surgeon and the lesion as well as the presence of major neurovascular structures surrounding the lesion may limit surgical exposure. A midline transsphenoidal route avoids transgression of the neurovascular plane and provides direct access to the interpeduncular cistern. To safely access the interpeduncular fossa, it requires mobilization of the pituitary gland. The pituitary hemitransposition technique permits mobilization of the gland, while preserving its venous drainage and arterial supply to the gland on one of its sides, preserving gland function. The authors aim to describe the intradural pituitary hemitransposition technique and to demonstrate its safe application for resection of skull base tumors in the retrosellar space. METHODS The authors describe the surgical technique and illustrate its application in 5 cases of different types of skull base tumors, including a video demonstrating all the steps to perform this approach. In addition, the authors discuss the advantages and limitations of this technique compared with other approaches to the retrosellar space. RESULTS The intradural pituitary hemitransposition technique was used to safely resect a chondrosarcoma, chordoma, craniopharyngioma, teratoma, and meningioma involving the parasellar and retrosellar spaces, while minimizing endocrine morbidity. We had one patient with mild, albeit permanent hyperprolactinemia and hypothyroidism after surgery. No other patients had permanent dysfunction related to surgery. CONCLUSION The endonasal endoscopic intradural pituitary hemitransposition approach is an effective technique for resection of lesions located within the retrosellar and petroclival regions, allowing adequate exposure while potentially optimizing the preservation of the pituitary function.
Collapse
Affiliation(s)
- Joao Paulo Almeida
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Guilherme Finger
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthieu D Weber
- The Ohio State University College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Mark A Damante
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kyle C Wu
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Patrick Walz
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jeffrey R Leonard
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ricardo L Carrau
- Department of Otolaryngology and Skull Base Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| |
Collapse
|
5
|
Vaz MAS, Monteiro JM, Tzu WH, Neto MR, Holanda VD, Figueiredo EG, Isolan GR. Professor Evandro de Oliveira, a guiding light in skull base surgery and vascular neurosurgery. Surg Neurol Int 2022; 13:229. [PMID: 35855122 PMCID: PMC9282787 DOI: 10.25259/sni_75_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/28/2022] [Indexed: 12/01/2022] Open
Affiliation(s)
| | - Jander Moreira Monteiro
- Department of Neurosurgery, The Center for Advanced Neurology and Neurosurgery, Porto Alegre, Rio Grande do Sul,
| | - Wen Hung Tzu
- Department of Neurosurgery, University of São Paulo, Faculdade das Clinicas,
| | - Mateus Reghin Neto
- Department of Microsurgical Laboratory, Beneficencia Portuguesa Hospital, São Paulo, Brazil
| | - Vanessa de Holanda
- Department of Microsurgical Laboratory, Beneficencia Portuguesa Hospital, São Paulo, Brazil
| | | | - Gustavo Rassier Isolan
- Department of Neurosurgery, The Center for Advanced Neurology and Neurosurgery, Porto Alegre, Rio Grande do Sul,
| |
Collapse
|
6
|
Luzzi S, Giotta Lucifero A, Spina A, Baldoncini M, Campero A, Elbabaa SK, Galzio R. Cranio-Orbito-Zygomatic Approach: Core Techniques for Tailoring Target Exposure and Surgical Freedom. Brain Sci 2022; 12:brainsci12030405. [PMID: 35326360 PMCID: PMC8946068 DOI: 10.3390/brainsci12030405] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/13/2022] [Accepted: 03/15/2022] [Indexed: 11/21/2022] Open
Abstract
Background: The cranio-orbito-zygomatic (COZ) approach is a workhorse of skull base surgery, and each of its steps has a precise effect on target exposure and surgical freedom. The present study overviews the key techniques for execution and tailoring of the COZ approach, focusing on the quantitative effects resulting from removal of the orbitozygomatic (OZ) bar, orbital rim, and zygomatic arch. Methods: A PRISMA-based literature review was performed on the PubMed/Medline and Web of Science databases using the main keywords associated with the COZ approach. Articles in English without temporal restriction were included. Eligibility was limited to neurosurgical relevance. Results: A total of 78 articles were selected. The range of variants of the COZ approach involves a one-piece, two-piece, and three-piece technique, with a decreasing level of complexity and risk of complications. The two-piece technique includes an OZ and orbitopterional variant. Superolateral orbitotomy expands the subfrontal and transsylvian corridors, increasing surgical freedom to the basal forebrain, hypothalamic region, interpeduncular fossa, and basilar apex. Zygomatic osteotomy shortens the working distance of the pretemporal and subtemporal routes. Conclusion: Subtraction of the OZ bar causes a tremendous increase in angular exposure of the subfrontal, transsylvian, pretemporal, and subtemporal perspectives avoiding brain retraction, allowing for multiangled trajectories, and shortening the working distance. The COZ approach can be tailored based on the location of the lesion, thus optimizing the target exposure and surgical freedom and decreasing the risk of complications.
Collapse
Affiliation(s)
- Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Correspondence:
| | - Alice Giotta Lucifero
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
| | - Alfio Spina
- Department of Neurosurgery and Gamma Knife Radiosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy;
| | - Matías Baldoncini
- Department of Neurological Surgery, Hospital San Fernando, Buenos Aires 1646, Argentina;
- Laboratory of Microsurgical Neuroanatomy, Second Chair of Gross Anatomy, School of Medicine, University of Buenos Aires, Buenos Aires 1053, Argentina
| | - Alvaro Campero
- Laboratorio de Innovaciones Neuroquirúrgicas de Tucuman (LINT), Facultad de Medicina, Universidad Nacional de Tucumán, Tucuman 4000, Argentina;
- Department of Neurosurgery, Hospital Padilla, San Miguel de Tucumán, Tucuman 4000, Argentina
| | - Samer K. Elbabaa
- Department of Pediatric Neurosurgery, Leon Pediatric Neuroscience Center of Excellence, Arnold Palmer Hospital for Children, Orlando, FL 32806, USA;
| | - Renato Galzio
- Neurosurgery Unit, Maria Cecilia Hospital, 48033 Cotignola, Italy;
| |
Collapse
|
7
|
Huang M, Su J, Xiao Q, Ma Q, Long W, Liu Q. Pretemporal Transcavernous Approach for Resection of Non-meningeal Tumors of the Cavernous Sinus: Single Center Experience. Front Surg 2022; 9:810606. [PMID: 35252332 PMCID: PMC8891164 DOI: 10.3389/fsurg.2022.810606] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 01/20/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesTo study the outcomes of the pretemporal transcavernous approach in the treatment of non-meningeal tumors involving cavernous sinus and to investigate the surgical strategy for these lesions.MethodsWe conducted a retrospective study of 45 patients with non-meningeal tumors involving cavernous sinus. All 45 patients received microsurgical resection via the pretemporal transcavernous approach from April 2012 to January 2019 by the same neurosurgeon. We analyzed clinical manifestations, image data, perioperative complications, surgical outcomes, functional outcomes, and follow-up data of these patients.ResultsGross total resection was achieved in 38 cases (84.4%) of the 45 patients. Preoperatively, a total of 64 individual cranial nerves were affected. Postoperatively, 92.2% of 64 impaired cranial nerves completely or partially restored function, 7.8% had worsened function compared with their preoperative statuses, and 5 new cranial nerve deficits (CNV) were observed in five patients during the last follow-up. Seven patients presented transient new cranial nerve deficits (5 CNIII and 2 CNVI), three cases suffered transient worsen cranial nerve deficits (3 CNIII and 1 CNVII). There were no cases of intracranial hematoma, intracranial infection, cerebrospinal fluid leaks, and death. The progression of residual tumor was observed in two patients (1 chordoma and 1 pituitary adenoma).ConclusionsNon-meningeal tumors involving cavernous sinus can be safely and radically removed with less morbidity and mortality. Pretemporal transcavernous approach is an ideal approach to the cavernous sinus and can be tailored individually.
Collapse
Affiliation(s)
- Meng Huang
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Jun Su
- Department of Neurosurgery in Hunan Children's Hospital, Changsha, China
| | - Qun Xiao
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Qianquan Ma
- Department of Neurosurgery in Peking University Third Hospital, Peking University, Beijing, China
| | - Wenyong Long
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
| | - Qing Liu
- Department of Neurosurgery in Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Qing Liu
| |
Collapse
|
8
|
Guadarrama-Ortiz P, Choreño-Parra JA, Garibay-Gracián A, Montes de Oca-Vargas I, Ruíz-Rivero CO, Capi-Casillas D, Alpízar-Acevedo AS, Prieto-Rivera ÁD, Castillo-Rangel C. Management of complex brain lesions arising at sellar, petroclival, and interpeduncular regions via the pretemporal approach: Technical note. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
9
|
Almeida JP, Quinones-Hinojosa A, Dagi TF. Commentary: Evandro de Oliveira in the Historical Context of Brazilian Neurosurgery. Neurosurgery 2021; 89:E264-E265. [PMID: 34392361 DOI: 10.1093/neuros/nyab313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 06/28/2021] [Indexed: 11/13/2022] Open
|
10
|
Bem Junior LS, Lemos NB, de Lima LFG, Dias AJA, Neto ODCF, de Lira CCS, Diniz AMS, Rabelo NN, Barroso LKV, Valença MM, de Azevedo Filho HRC. The anatomy of the brain - learned over the centuries. Surg Neurol Int 2021; 12:319. [PMID: 34345460 PMCID: PMC8326080 DOI: 10.25259/sni_200_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/07/2021] [Indexed: 12/30/2022] Open
Abstract
This article reports the evolution and consolidation of the knowledge of neuroanatomy through the analysis of its history. Thus, we propose to describe in a historical review to summarize the main theories and concepts that emerged throughout brain anatomy history and understand how the socio-historical context can reflect on the nature of scientific knowledge. Therefore, among the diverse scientists, anatomists, doctors, and philosophers who were part of this history, there was a strong influence of the studies of Claudius Galen (AD 129-210), Leonardo da Vinci (1452- 1519), Andreas Vesalius (1514-1564), Franciscus Sylvius (1614-1672), Luigi Rolando (1773-1831), Pierre Paul Broca (1824-1880), Carl Wernicke (1848-1905), Korbinian Brodmann (1868-1918), Wilder Penfield (1891-1976), Mahmut Gazi Yasargil (1925), and Albert Loren Rhoton Jr. (1932-2016) on the fundamentals of neuroanatomy.
Collapse
Affiliation(s)
- Luiz Severo Bem Junior
- College of Medical Sciences, Unifacisa University Center, Campina Grande, Paraíba
- Neuroscience Post-Graduate Program, Federal University of Pernambuco, Recife, Pernambuco
| | - Nilson Batista Lemos
- College of Medical Sciences, Unifacisa University Center, Campina Grande, Paraíba
| | | | | | | | | | | | | | | | - Marcelo Moraes Valença
- Neuroscience Post-Graduate Program, Federal University of Pernambuco, Recife, Pernambuco
| | | |
Collapse
|
11
|
Ortiz-Rafael J, Chakravarthi SS, Revuelta-Gutiérrez R, Kassam A, Monroy-Sosa A. Microsurgical anatomy of the cranial nerve-centric triangles of the posterior cranial base: cadaveric and radiological anatomical study. Anat Sci Int 2021; 96:531-543. [PMID: 34132987 DOI: 10.1007/s12565-021-00620-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 06/09/2021] [Indexed: 11/26/2022]
Abstract
Tumors in the posterior fossa can be situated either dorsal and lateral, ventral and medial, or occupying both regions in relation to the cranial nerves, with the latter position being especially challenging. In an effort to organize neurovascular complexes contained within, anatomically based triangles have been proposed to serve as guiding landmarks for locating critical neurovascular structures. The objectives of this study were to: (1) provide a review of historical anatomically based vascular-centric triangles of the posterior fossa based on respective neurovascular complexes; (2) introduce a more organized alternative system of triangles with the conceptualization of a projection system from superficial to deep; and (3) propose and describe two new triangles of the posterior fossa: Petrous-Acousticofacial and Acousticofacial-Trigeminal. Five cadavers were studied. Neurovascular complexes were described with the use of anatomically guided cranial nerve-centric triangles, each of which was formed by cranial nerves, petrous bone, brainstem, tentorium, and superior petrosal vein. All triangles were measured and anatomical boundaries confirmed by neuronavigation. Two circumferential frameworks were created to correlate superficial and deep anatomy: (1) Outer circumference and (2) Inner circumference. Posterior fossa was divided into the following: (1) Superior complex-corresponds to the sub-asterional region, which was projected to the trigeminal nerve; (2) Middle complex-corresponds to the mastoid emissary vein foramen, which was projected to the facial and vestibulocochlear nerves; and (3) Inferior complex-corresponds to the posterior condylar canal, which projects to the lower cranial nerves. Neuronavigation confirmed these landmarks. Two new triangles were proposed: (1) The Petrous-Acousticofacial triangle, and (2) The Acousticofacial-Trigeminal triangle. Triangles provide a useful anatomical guide to the posterior fossa. We have introduced an organized schema, as well as proposed two new triangles, with the intent to minimize manipulation of neurovascular structures.
Collapse
Affiliation(s)
| | - Srikant S Chakravarthi
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, W Kinnikinic River Pkwy #680, 2801, Milwaukee, WI, 53215, USA
- Skull Base, and Cerebrovascular Lab Aurora Research Institute, Milwaukee, WI, USA
| | - Rogelio Revuelta-Gutiérrez
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery "Manuel Velasco Suárez", México City, Mexico
| | | | - Alejandro Monroy-Sosa
- Department of Neurosurgery, Aurora Neuroscience Innovation Institute, Aurora St. Luke's Medical Center, W Kinnikinic River Pkwy #680, 2801, Milwaukee, WI, 53215, USA.
- Skull Base, and Cerebrovascular Lab Aurora Research Institute, Milwaukee, WI, USA.
- Department of Neurosurgery, Institute for Social Security and Services for State Workers Tláhuac, Mexico City, Mexico.
| |
Collapse
|
12
|
Zhao X, Labib MA, Shaffer KV, Moreira LB, Ramanathan D, Naeem K, Belykh E, Lawton MT, Lopez-Gonzalez MA, Preul MC. Tailoring the surgical corridor to the basilar apex in the pretemporal transcavernous approach: morphometric analyses of different neurovascular mobilization maneuvers. Acta Neurochir (Wien) 2020; 162:2731-2741. [PMID: 32757048 DOI: 10.1007/s00701-020-04490-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 07/10/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND The pretemporal transcavernous approach (PTA) provides optimal exposure and access to the basilar artery (BA); however, the PTA can be invasive when vital neurovascular structures are mobilized. The goal of this study was to evaluate mobilization strategies to tailor approaches to the BA. METHODS After an orbitozygomatic craniotomy, 10 sides of 5 cadaveric heads were used to assess the surgical access to the BA via the opticocarotid triangle (OCT), carotid-oculomotor triangle (COT), and oculomotor-tentorial triangle (OTT). Measurements were obtained, and morphometric analyses were performed for natural neurovascular positions and after each stepwise expansion maneuver. An imaginary line connecting the midpoints of the limbus sphenoidale and dorsum sellae was used as a reference to normalize the measurements of BA exposure and to facilitate the clinical applicability of this technique. RESULTS In the OCT, the exposed BA segment ranged from - 1 ± 3.9 to + 6 ± 2.0 mm in length in its natural position. In the COT, the accessible BA segment ranged from - 4 ± 2.3 to - 2 ± 3.0 mm in length in its natural position. Via the OTT, the accessible BA segment ranged from - 7 ± 2.6 to - 5 ± 2.8 mm in length in its natural position. In the OCT, COT, and OTT, a posterior clinoidectomy extended the exposure down to - 6 ± 2.7, - 8 ± 2.5, and - 9 ± 2.9 mm, respectively. CONCLUSIONS This study quantitatively evaluated the need for the expansion maneuvers in the PTA to reach BA aneurysms according to the patient's anatomical characteristics.
Collapse
Affiliation(s)
- Xiaochun Zhao
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Mohamed A Labib
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Kurt V Shaffer
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Leandro Borba Moreira
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Dinesh Ramanathan
- Department of Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Komal Naeem
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Evgenii Belykh
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Michael T Lawton
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | | | - Mark C Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA.
| |
Collapse
|
13
|
Meybodi AT, Benet A, Vigo V, Rubio RR, Yousef S, Mokhtari P, Dones F, Kakaizada S, Lawton MT. Assessment of the endoscopic endonasal approach to the basilar apex region for aneurysm clipping. J Neurosurg 2019; 130:1937-1948. [PMID: 29932384 PMCID: PMC6746604 DOI: 10.3171/2018.1.jns172813] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/04/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The expanded endoscopic endonasal approach (EEA) has shown promising results in treatment of midline skull base lesions. Several case reports exist on the utilization of the EEA for treatment of aneurysms. However, a comparison of this approach with the classic transcranial orbitozygomatic approach to the basilar apex (BAX) region is missing.The present study summarizes the results of a series of cadaveric surgical simulations for assessment of the EEA to the BAX region for aneurysm clipping and its comparison with the transcranial orbitozygomatic approach as one of the most common approaches used to treat BAX aneurysms. METHODS Fifteen cadaveric specimens underwent bilateral orbitozygomatic craniotomies as well as an EEA (first without a pituitary transposition [PT] and then with a PT) to expose the BAX. The following variables were measured, recorded, and compared between the orbitozygomatic approach and the EEA: 1) number of perforating arteries counted on bilateral posterior cerebral arteries (PCAs); 2) exposure and clipping lengths of the PCAs, superior cerebellar arteries (SCAs), and proximal basilar artery; and 3) surgical area of exposure in the BAX region. RESULTS Except for the proximal basilar artery exposure and clipping, the orbitozygomatic approach provided statistically significantly greater values for vascular exposure and control in the BAX region (i.e., exposure and clipping of ipsilateral and contralateral SCAs and PCAs). The EEA with PT was significantly better in exposing and clipping bilateral PCAs compared to EEA without a PT, but not in terms of other measured variables. The surgical area of exposure and PCA perforator counts were not significantly different between the 3 approaches. The EEA provided better exposure and control if the BAX was located ≥ 4 mm inferior to the dorsum sellae. CONCLUSIONS For BAX aneurysms located in the retrosellar area, PT is usually required to obtain improved exposure and control for the bilateral PCAs. However, the transcranial approach is generally superior to both endoscopic approaches for accessing the BAX region. Considering the superior exposure of the proximal basilar artery obtained with the EEA, it could be a viable option when surgical treatment is considered for a low-lying BAX or mid-basilar trunk aneurysms (≥ 4 mm inferior to dorsum sellae).
Collapse
Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Arnau Benet
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Vera Vigo
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | - Roberto Rodriguez Rubio
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | - Sonia Yousef
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | - Pooneh Mokhtari
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | - Flavia Dones
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | - Sofia Kakaizada
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | - Michael T. Lawton
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| |
Collapse
|
14
|
da Silva SA, Yamaki VN, Solla DJF, Andrade AFD, Teixeira MJ, Spetzler RF, Preul MC, Figueiredo EG. Pterional, Pretemporal, and Orbitozygomatic Approaches: Anatomic and Comparative Study. World Neurosurg 2018; 121:e398-e403. [PMID: 30266695 DOI: 10.1016/j.wneu.2018.09.120] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/12/2018] [Accepted: 09/15/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Although pterional craniotomy and its variants are the most used approaches in neurosurgery, few studies have evaluated their precise indications. We evaluate the pterional (PT), pretemporal (PreT), and orbitozygomatic (OZ) approaches through quantitative measurements of area, linear, and angular exposures of the major intracranial vascular structures. METHODS Eight fresh, adult cadavers were operated with the PT, followed by the PreT, and ending with the OZ approach. The working area, angular exposure of vascular structures and linear exposure of the basilar artery were measured. RESULTS The OZ approach presented a wider area (1301.3 ± 215.9 mm2) with an increase of 456.7 mm2 compared with the PT and of 167.4 mm2 to the PreT (P = 0.011). The extension from PT to PreT and OZ increases linear exposure of the basilar artery. When comparing the PreT and OZ, we found an increase in the horizontal and vertical angle to the bifurcation of the ipsilateral middle cerebral artery (P = 0.005 and P = 0.032, respectively), horizontal angle to the basilar artery tip (P = 0.02), and horizontal angle to the contralateral ICA bifurcation (P = 0.048). CONCLUSIONS The OZ approach offered notable surgical advantages compared with the traditional PT and PreT regarding to the area of exposure and linear exposure to basilar artery. Regarding angle of attack, the orbital rim and zygomatic arch removal provided quantitatively wider exposure and increased surgical freedom. A detailed anatomic study for each patient and surgeon experience must be considered for individualized surgical approach indication.
Collapse
Affiliation(s)
- Saul Almeida da Silva
- Division of Neurological Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Vitor Nagai Yamaki
- Division of Neurological Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Davi Jorge Fontoura Solla
- Division of Neurological Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Almir Ferreira de Andrade
- Division of Neurological Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Manoel Jacobsen Teixeira
- Division of Neurological Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Eberval Gadelha Figueiredo
- Division of Neurological Surgery, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
| |
Collapse
|
15
|
Tayebi Meybodi A, Benet A, Rodriguez Rubio R, Yousef S, Mokhtari P, Preul MC, Lawton MT. Comparative Analysis of Orbitozygomatic and Subtemporal Approaches to the Basilar Apex: A Cadaveric Study. World Neurosurg 2018; 119:e607-e616. [PMID: 30077027 DOI: 10.1016/j.wneu.2018.07.217] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/23/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The subtemporal and orbitozygomatic approaches are the most commonly used surgical approaches for the treatment of basilar artery apex (BAX) aneurysms. Relative advantages and disadvantages are generally reported based on surgeons' experience. This study was performed to provide a detailed comparison between the subtemporal and orbitozygomatic approaches based on cadaveric dissection analysis for the treatment of BAX aneurysms. METHODS Subtemporal and orbitozygomatic approaches were performed on 5 cadaveric heads (10 sides), and the following variables were assessed and compared between the 2 approaches: 1) number of exposed perforators on P1-posterior cerebral arteries (PCA); 2) lengths of exposure and clipping for bilateral PCA, superior cerebellar arteries (SCA), and basilar trunk; 3) surgical area of exposure; and 4) surgical freedom at the BAX. RESULTS Number of perforators exposed on P1-PCA was not different between the subtemporal and orbitozygomatic approaches. Exposure and clipping of ipsilateral SCA and PCA were superior using the subtemporal approach, and better for contralateral SCA and PCA using the orbitozygomatic approach, all reaching statistical significance. The orbitozygomatic approach provided greater exposure and clipping length for the proximal basilar trunk. Although the surgical area of exposure was similar between the 2 approaches, the overall surgical freedom was greater in the orbitozygomatic approach. CONCLUSIONS The orbitozygomatic approach provides a greater number of surgical corridors to the BAX and is superior regarding multiple surgically relevant anatomic parameters. Importantly, control over the basilar trunk and over the contralateral SCA and PCA (blind spots) is superior with the orbitozygomatic approach.
Collapse
Affiliation(s)
- Ali Tayebi Meybodi
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Arnau Benet
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Sonia Yousef
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, USA
| | - Pooneh Mokhtari
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Mark C Preul
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Michael T Lawton
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
| |
Collapse
|
16
|
Spiessberger A, Strange F, Fandino J, Marbacher S. Microsurgical Clipping of Basilar Apex Aneurysms: A Systematic Historical Review of Approaches and their Results. World Neurosurg 2018; 114:305-316. [PMID: 29602006 DOI: 10.1016/j.wneu.2018.03.141] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/19/2018] [Accepted: 03/20/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Neck clipping remains a valuable treatment option for basilar apex aneurysms, especially in those with complex morphology, such as incorporation of branching vessels or large size, and young patient age. Several approaches have proved to give effective exposure for various types of lesion morphologies. Our historic literature review from 1976 to the present systematically compares the outcomes and complications of the key surgical approaches in the treatment of basilar apex aneurysms. METHODS We searched PubMed for articles with at least 5 patients, data on neurologic outcome, and procedure-associated complications for the following approaches: pterional or orbitozygomatic transsylvian, subtemporal (with or without zygomatic osteotomy), pretemporal (with or without transcavernous extension), and transpetrous. n-Weighted averages for clinical outcome, aneurysm occlusion rates, morbidity, mortality, and aneurysm morphology were compared. RESULTS Of 35 articles selected, 2041 patients with 722 ruptured aneurysms underwent microsurgery, including 1131 transsylvian, 241 pretemporal, 375 subtemporal, and 17 transpetrous approaches. Comparing these 4 approaches in n-weighted averages, respectively, we noted good neurologic outcomes (81%, 85%, 81%, and 58%), surgical morbidity (14%, 10%, 34%, and 53%), surgical mortality (4%, 1%, 0, and 1%), and complete occlusion rates (95%, 94%, 86%, and 75%). CONCLUSIONS Transsylvian, pretemporal, and subtemporal approaches showed favorable neurologic outcomes at similar rates and were applied for aneurysms located between -1mm and +7mm in relation to the posterior clinoid process. The pretemporal approach was preferably applied to large and giant aneurysms with good outcome; the transsylvian approach was most frequently used for ruptured aneurysms.
Collapse
Affiliation(s)
| | - Fabio Strange
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| |
Collapse
|
17
|
Less is more: Parahippocampal resection or endoscopic assistance in ambient cistern surgery? Qualitative and quantitative assessment of subtemporal approach. J Clin Neurosci 2018; 53:203-208. [PMID: 29685409 DOI: 10.1016/j.jocn.2018.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/09/2018] [Indexed: 11/20/2022]
Abstract
The ambient cistern is an arachnoid complex that extends from the crural cistern to lateral border of cerebral colliculi. The subtemporal approach has been recognized as the best access to reach pathologies in the ambient cistern, however many disadvantages exist. The present work aims to analyze quantitatively the area of exposure provided by the subtemporal access. The objective is to evaluate if there are advantages of using the neuroendoscope in conventional subtemporal access when compared to the subtemporal access with resection of the parahippocampal gyrus. A subtemporal approach was performed in six brain hemispheres. Qualitative and quantitative analyses were made. The linear exposition of the vascular structures and the surgical exposure area were evaluated. The linear exposure to the posterior cerebral artery was 5.95 for subtemporal access (ST) and 13.6 for subtemporal access with resection of the parahippocampal gyrus (STh) (p = 0.019). The total exposure area was 104.8 mm2 for ST and 210.5 for STh (p = 0.0001). Regarding endoscope assistance the medial area, ST was 81.0 mm2, and STend was 176.2 mm2 (p = 0.038). For the total area of exposure, we obtained a value of 210.5 mm2 for ST and a value of 391.3 mm2 for STend (p = 0.041). In conventional subtemporal access, the use of the neuroendoscopes avoids the need for resection of the parahippocampal gyrus for better visualization of the ambient cistern structures.
Collapse
|
18
|
de Notaris M, Laleva L, Spiriev T, Dallan I, Di Nuzzo G, Pineda J, Prats-Galino A, Catapano G. Frontolateral Approach Combined with Endoscopic Endonasal Extradural Posterior Clinoidectomy to the Upper Clival Region: Anatomic and Feasibility Study. World Neurosurg 2017; 111:86-93. [PMID: 29269065 DOI: 10.1016/j.wneu.2017.12.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/04/2017] [Accepted: 12/08/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Surgical management of lesions located in the upper clival region is challenging. Complex open transcranial approaches have been used to reach surgical targets in these areas. The frontotemporozygomatic approach combined with an intradural posterior clinoidectomy has been proposed as the most reliable route to manage such lesions. We investigated combining a minimally invasive endoscopic endonasal extradural posterior clinoidectomy (EPC) with a standard frontolateral approach to expand the working area within the upper clival region. METHODS Investigators dissected 10 human cadaveric heads at the Laboratory of Surgical NeuroAnatomy of the University of Barcelona. The heads were positioned to simulate a supine position, enabling the simultaneous use of both endonasal and frontolateral routes. The dissections were divided into 3 steps-standard frontolateral approach, EPC, and re-evaluation of the frontolateral route-aiming to compare the surgical exposure before and after EPC. RESULTS After EPC, through the frontolateral pathway it was possible to improve visualization and working angles to the interpeduncular fossa and retrosellar and upper clival regions. Increase in extension of the carotid-oculomotor window was 7 mm and 10 mm before and after the posterior clinoidectomy, respectively. CONCLUSIONS EPC provided extra working space for the frontolateral approach to the upper clival area with 42.8% expansion of the carotid-oculomotor triangle. Surgical series are needed to demonstrate clinical advantages and disadvantages of this novel combined approach.
Collapse
Affiliation(s)
- Matteo de Notaris
- Department of Neuroscience, "G. Rummo" Hospital, Neurosurgery Operative Unit, Benevento, Italy.
| | - Lili Laleva
- Unit of Otorhinolaryngology, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Toma Spiriev
- Unit of Otorhinolaryngology, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Iacopo Dallan
- Department of Neurosurgery, Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Giuseppe Di Nuzzo
- Department of Neuroscience, "G. Rummo" Hospital, Neurosurgery Operative Unit, Benevento, Italy
| | - Jose Pineda
- Laboratory of Surgical NeuroAnatomy, Human Anatomy and Embryology Unit, University of Barcelona Faculty of Medicine, Barcelona, Spain
| | - Alberto Prats-Galino
- Laboratory of Surgical NeuroAnatomy, Human Anatomy and Embryology Unit, University of Barcelona Faculty of Medicine, Barcelona, Spain
| | - Giuseppe Catapano
- Department of Neuroscience, "G. Rummo" Hospital, Neurosurgery Operative Unit, Benevento, Italy
| |
Collapse
|
19
|
History, Evolution, and Continuing Innovations of Intracranial Aneurysm Surgery. World Neurosurg 2017; 102:673-681. [DOI: 10.1016/j.wneu.2017.02.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 01/30/2017] [Accepted: 02/01/2017] [Indexed: 12/19/2022]
|
20
|
Delaunois J, Vaz G, Raftopoulos C. Transsylvian Transuncal Approach for an Anterior Midbrain Cavernous Malformation Resection: A Case Report. Oper Neurosurg (Hagerstown) 2017; 14:E38-E43. [DOI: 10.1093/ons/opx116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 05/02/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE
Cavernous malformations (CMs) are vascular abnormalities with a hemorrhage risk of 0.2% to 5% per year, according to their location. Brainstem CMs seem to have a greater hemorrhagic risk and represent a neurosurgical challenge. We report here the first transsylvian transuncal (TS-TU) approach for an anteromedial mesencephalic CM resection.
CLINICAL PRESENTATION
A 29-yr-old female suddenly presented a left hemiparesis and central facial paresis with a diplopia in the upward gaze. A cerebral imagery revealed an 18-mm right cerebral peduncle CM with signs of acute hemorrhage. Two months later, she rebleed while pregnant. The pregnancy was interrupted. Five months later, a 3.0 Tesla magnetic resonance imaging (MRI) with diffusion tensor imaging sequences was realized for preoperative planning followed by a gross total resection of the CM through a TS-TU approach to avoid the perforating arteries of the anterior perforated substance. The patient presented postoperatively again a left hemiparesis and central facial paresis with a right oculomotor nerve paresis. On the tenth postsurgical day, she developed a Holmes’ tremor of the left upper limb, for which a Levodopa treatment was initiated. Three months postoperative, MRI showed a gross total resection of the mesencephalic CM without complications. A complete clinical recovery was observed 1 yr later.
CONCLUSION
We describe here the first performance of a TS-TU approach for an anterior mesencephalic CM resection. This surgical approach allowed direct access to the CM, avoiding the vascularization of the anterior perforated substance.
Collapse
Affiliation(s)
- Julien Delaunois
- Department of Neurosurgery, Cliniques Universitaires Saint-Luc, Université Cath-olique de Louvain, Brussels, Belgium
| | - Géraldo Vaz
- Department of Neurosurgery, Cliniques Universitaires Saint-Luc, Université Cath-olique de Louvain, Brussels, Belgium
| | - Christian Raftopoulos
- Department of Neurosurgery, Cliniques Universitaires Saint-Luc, Université Cath-olique de Louvain, Brussels, Belgium
| |
Collapse
|
21
|
Nakov VS, Spiriev TY, Todorov IT, Simeonov P. Technical nuances of subtemporal approach for the treatment of basilar tip aneurysm. Surg Neurol Int 2017; 8:15. [PMID: 28217394 PMCID: PMC5309464 DOI: 10.4103/2152-7806.199555] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 11/10/2016] [Indexed: 11/17/2022] Open
Abstract
Background: Basilar tip aneurysms are one of the most complex vascular lesions to treat surgically because of their location, depth of the approach, and close proximity of vital neurovascular structures such as the mesencephalon, cranial nerves, perforating arteries to the thalamus. There are different surgical approaches utilized to reach basilar tip aneurysms, namely, pterional, pretemporal, orbitozygomatic, subtemporal, and anterior petrosectomy. Each of them has its advantages and limitations. Methods: In this paper, we present our personal experience with the use of subtemporal approach. The technique is described in detail including its nuances and potential pitfalls. Results: The subtemporal approach is indicated for basilar tip aneurysms located at the level of the floor of the sella turcica to 1 cm above the dorsum sellae. Conclusion: Subtemporal approach offers good surgical corridor for the management of these complex vascular lesions.
Collapse
Affiliation(s)
| | - Toma Y Spiriev
- Department of Neurosurgery, Tokuda Hospital, Sofia, Bulgaria
| | - Ivan T Todorov
- Department of Neurosurgery, Military Medical Academy, Sofia, Bulgaria
| | - Plamen Simeonov
- Department of Neurosurgery, Military Medical Academy, Sofia, Bulgaria
| |
Collapse
|
22
|
Lateral transzygomatic middle fossa approach and its extensions: surgical technique and 3D anatomy. Clin Neurol Neurosurg 2014; 130:33-41. [PMID: 25576883 DOI: 10.1016/j.clineuro.2014.12.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 11/04/2014] [Accepted: 12/20/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Various approaches to lesions involving the middle fossa and cavernous sinus (CS), with and without posterior fossa extension have been described. In the present study, we describe the surgical technique for the extradural lateral tranzygomatic middle fossa approach and its extensions, highlight relevant 3D anatomy. METHODS Simulations of the lateral transzygomatic middle fossa approach and its extensions were performed in four silicon-injected formalin fixed cadaveric heads. The step-by-step description and relevant anatomy was documented with 3D photographs. RESULT The lateral transzygomatic middle fossa approach is particularly useful for lesions involving the middle fossa with and without CS invasion, extending to the posterior fossa and involving the clinoidal region. This approach incorporates direct lateral positioning of patient, frontotemporal craniotomy with zygomatic arch osteotomy, extradural elevation of the temporal lobe, and delamination of the outer layer of the lateral CS wall. Extradural drilling of the sphenoid wing and anterior clinoid process allows entry into the CS through the superior wall and exposure of the clinoidal segment of the ICA. Posteriorly, drilling the petrous apex allows exposure of the ventral brainstem from trigeminal to facial nerve and can be extended to the interpeduncular fossa by division of the superior petrosal sinus. CONCLUSION The present study illustrates 3D anatomical relationships of the lateral transzygomatic middle fossa approach with its extensions. This approach allows wide access to different topographic areas (clinoidal region and clinoidal ICA, the entire CS, and the posterior fossa from the interpeduncular fossa to the facial nerve) via a lateral trajectory. Precise knowledge of technique and anatomy is necessary to properly execute this approach.
Collapse
|
23
|
Doglietto F, Maira G. Transsphenoidal Surgery for Lesions Involving the Interpeduncular Fossa: What If the Path Is Not Created By the Tumor? World Neurosurg 2014; 81:275-8. [DOI: 10.1016/j.wneu.2013.01.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 01/12/2013] [Indexed: 10/27/2022]
|
24
|
Nanda A, Sonig A, Banerjee AD, Javalkar VK. Microsurgical management of basilar artery apex aneurysms: a single surgeon's experience from Louisiana State University, Shreveport. World Neurosurg 2013; 82:118-29. [PMID: 23851208 DOI: 10.1016/j.wneu.2013.06.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 04/13/2013] [Accepted: 06/29/2013] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Basilar artery apex aneurysms continue to generate technical challenges and management controversy. Endovascular intervention is becoming the mainstay in the management of these formidable aneurysms, but it has limitations, especially with large/giant or wide neck basilar apex aneurysms. There is paucity of data in the available literature pertaining to the successful management of large/giant, wide neck, and calcified/thrombosed basilar apex aneurysms. We present our experience with consecutively operated complex basilar apex aneurysms so as to present the role of microneurosurgery as a viable management option for these aneurysms. METHODS Ours is a retrospective analysis of case-records for operated cases of basilar artery aneurysms spanning 18 years. Basilar apex aneurysms >10 cm, calcified or thrombosed, neck ≥4 mm posterior direction, and retro/subsellar were considered as complex anatomy aneurysms. Basilar apex aneurysms with favorable anatomy were included in the study as a reference group for statistical analysis. Patient demographics, complex features of aneurysms, clinical grade, and outcomes were analyzed. RESULTS A total of 33 (53.2%) patients had complex anatomy: large (>10 mm) in eight (24.2%); giant aneurysms (>25 mm) in seven (21.2%); wide-neck in 22 (66.7%); and calcified/thrombosed morphology in five (15.1%). The mean age was 48.5 years, and 22 (66.67%) were women. All aneurysms were clipped by the use of various skull base approaches. A total of 71.9% of patients harboring complex aneurysm had good outcomes. If only unruptured and good grade complex aneurysms also are considered, then 86.9% (n = 20) patients had good outcomes. Statistically there was no significant difference in the outcomes of complex and noncomplex aneurysm. CONCLUSIONS Although concerning, the management of large/giant, wide neck, and calcified/thrombosed aneurysms with microneurosurgery is still a competitive alternative to endovascular therapy. After careful selection of appropriate skull base approaches based on the complexity of the basilar apex aneurysm, microneurosurgery can achieve acceptable results.
Collapse
Affiliation(s)
- Anil Nanda
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, Louisiana, USA.
| | - Ashish Sonig
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
| | - Anirban Deep Banerjee
- Department of Functional & Restorative Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vijay Kumar Javalkar
- Department of Neurology, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
| |
Collapse
|