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Song B, Wang Q, Ding Z, Lu X. Endoscopic Lateral and Superior Cerebellar Keyhole Approach to the Anterior and Middle Incisural Space and Meckel Cave: An Anatomic Study. World Neurosurg 2023; 178:e156-e164. [PMID: 37442539 DOI: 10.1016/j.wneu.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE We sought to assess the feasibility of endoscopic lateral and superior cerebellar keyhole approach for exposure of the anterior and middle incisural space and Meckel cave. METHODS The endoscopic lateral and superior cerebellar keyhole approach was performed in 6 cadaveric heads (12 sides) using 0- and 30-degree endoscopes, respectively. The anatomic structures for this approach to the anterior and middle incisural space and Meckel cave were observed. RESULTS By grinding out the suprameatal tubercle and petrous apex and incising the tentorium, the anatomic structures in the anterior incisural space were visualized. The mean area exposed with a 0-degree endoscope in the anterior incisural space was 212.50 ± 6.04 mm2, significantly less than that exposed with a 30-degree endoscope (233.83 ± 8.72 mm2) (P < 0.05). The anatomic distance of the Meckel cave in the depth was the same between a 0-degree endoscope and a 30-degree endoscope; however, the distance in the width was 9.48 and 12.32 mm, respectively (P < 0.01). The area of petrous window grinded by a 30-degree endoscope was only increased by 5.83 mm2, compared with a 0-degree endoscope (P > 0.05). CONCLUSIONS This approach provides access to the anterior and middle incisural space and Meckel cave, which is feasible to clearly expose the anatomic structures in those regions with minimal invasiveness. Additionally, better visualization and surgical space can be achieved under a 30-degree endoscope.
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Affiliation(s)
- Bingwei Song
- Wuxi Clinical Medical College of Nanjing Medical University, Wuxi, Jiangsu Province, China
| | - Qing Wang
- Department of Neurosurgery, Wuxi No. 2 People's Hospital, Wuxi, Jiangsu Province, China
| | - Zhemin Ding
- Department of Neurosurgery, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu Province, China
| | - Xiaojie Lu
- Wuxi Clinical Medical College of Nanjing Medical University, Wuxi, Jiangsu Province, China; Department of Neurosurgery, Wuxi No. 2 People's Hospital, Wuxi, Jiangsu Province, China.
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2
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Kurucz P, Ganslandt O, Buchfelder M, Barany L. Microsurgical anatomy and pathoanatomy of the outer arachnoid membranes in the cerebellopontine angle: cadaveric and intraoperative observations. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05601-x. [PMID: 37133788 DOI: 10.1007/s00701-023-05601-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/17/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE The cerebellopontine angle (CPA) is a frequent region of skull base pathologies and therefore a target for neurosurgical operations. The outer arachnoid is the key structure to approach the here located lesions. The goal of our study was to describe the microsurgical anatomy of the outer arachnoid of the CPA and its pathoanatomy in case of space-occupying lesions. METHODS Our examinations were performed on 35 fresh human cadaveric specimens. Macroscopic dissections and microsurgical and endoscopic examinations were performed. Retrospective analysis of the video documentations of 35 CPA operations was performed to describe the pathoanatomical behavior of the outer arachnoid. RESULTS The outer arachnoid cover is loosely attached to the inner surface of the dura of the CPA. At the petrosal surface of the cerebellum the pia mater is strongly adhered to the outer arachnoid. At the level of the dural penetration of the cranial nerves, the outer arachnoid forms sheath-like structures around the nerves. In the midline, the outer arachnoid became detached from the pial surface and forms the base of the posterior fossa cisterns. In pathological cases, the outer arachnoid became displaced. The way of displacement depends on the origin of the lesion. The most characteristic patterns of changes of the outer arachnoid were described in case of meningiomas, vestibular schwannomas, and epidermoid cysts of the CPA. CONCLUSION The knowledge of the anatomy of the outer arachnoid of the cerebellopontine region is essential to safely perform microsurgical approaches as well as of dissections during resection of pathological lesions.
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Affiliation(s)
- Peter Kurucz
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanalage 60, 91054, Erlangen, Germany.
- Department of Neurosurgery, Katharinenhospital, Klinikum Stuttgart, Stuttgart, Germany.
| | - Oliver Ganslandt
- Department of Neurosurgery, Katharinenhospital, Klinikum Stuttgart, Stuttgart, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanalage 60, 91054, Erlangen, Germany
| | - Laszlo Barany
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanalage 60, 91054, Erlangen, Germany
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary
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3
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Bayatli E, Ozgural O, Eroglu U, Dogan I, Hasimoglu S, Bozkurt M, Kahilogullari G, Ugur HC, Unlu A. Posterior fossa epidermoid tumors: a single-center study and proposed classification system. Br J Neurosurg 2022:1-9. [PMID: 35037530 DOI: 10.1080/02688697.2021.2022099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 12/15/2021] [Accepted: 12/20/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND Epidermoid tumors of the cerebellopontine angle and posterior fossa account for approximately 1% of all intracranial tumors. Classifications that may guide surgical planning in the current neurosurgical practice are lacking. This study aimed to focus on the surgical outcome and suggest a classification system that may aid neurosurgeons in determining the goal of resection to minimize morbidity and mortality rates. METHODS The study population comprised patients who underwent surgery and follow-up for tissue-proven epidermoid tumors between 2015 and 2020. Patients' data, including demographic features, clinical symptomatology, the extent of surgical resection, and postoperative outcomes, were retrospectively evaluated. A new classification system was designed based on the anatomical-radiological findings and was evaluated in terms of clinical symptomatology, radiological features, surgical approach, and postoperative outcomes. RESULTS The patient population comprised 22 women (57.9%) and 16 men (42.1%), with a mean age of 34.9 years. A practical classification system based on the radiological-anatomical vertical (1, 2, and 3) and horizontal (a, b, and c) tumor extensions was designed. No significant differences were found in the patients in terms of sex/age. The most commonly observed symptom was gait disturbance (34.2%). The preoperative tumor diameter was significantly larger in the subtotal resection (STR) group than in the gross total resection (GTR) and near-total resection (NTR) groups. Significantly more cistern involvement was observed in the STR group than in the GTR group. The GTR, NTR, and STR rates were higher in grade 1, 3, and 2 cases, respectively. The subgroup 'a' was correlated with higher resection rates (GTR and NTR), whereas the subgroup 'b' was correlated with STR. CONCLUSIONS Our suggested classification system represents a simple and practical model that may guide neurosurgeons in predicting the goal of resection during surgical planning and in minimizing potential morbidity.
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Affiliation(s)
- Eyüp Bayatli
- Department of Neurosurgery, School of Medicine, Ankara University, Ankara, Turkey
| | - Onur Ozgural
- Department of Neurosurgery, School of Medicine, Ankara University, Ankara, Turkey
| | - Umit Eroglu
- Department of Neurosurgery, School of Medicine, Ankara University, Ankara, Turkey
| | - Ihsan Dogan
- Department of Neurosurgery, School of Medicine, Ankara University, Ankara, Turkey
| | - Siavash Hasimoglu
- Department of Neurosurgery, School of Medicine, Ankara University, Ankara, Turkey
| | - Melih Bozkurt
- Department of Neurosurgery, School of Medicine, Ankara University, Ankara, Turkey
| | - Gokmen Kahilogullari
- Department of Neurosurgery, School of Medicine, Ankara University, Ankara, Turkey
| | - Hasan Caglar Ugur
- Department of Neurosurgery, School of Medicine, Ankara University, Ankara, Turkey
| | - Agahan Unlu
- Department of Neurosurgery, School of Medicine, Ankara University, Ankara, Turkey
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4
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Fouda MA, Jeelani Y, Gokoglu A, Iyer RR, Cohen AR. Endoscope-assisted microsurgical retrosigmoid approach to the lateral posterior fossa: Cadaveric model and a review of literature. Surg Neurol Int 2021; 12:416. [PMID: 34513180 PMCID: PMC8422411 DOI: 10.25259/sni_157_2021] [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: 02/13/2021] [Accepted: 07/20/2021] [Indexed: 11/09/2022] Open
Abstract
Background: The advancement of endoscopic techniques in the past decade has improved the surgical management of cerebellopontine angle (CPA) tumors. Endoscope-assisted microsurgery improves the ability to evaluate the extent of resection, achieve safe tumor resection and reduce the risk of surgery-related morbidity. Methods: In this study, we used a cadaveric model to demonstrate a step by step endoscope-assisted microsurgery of the retrosigmoid approach to the lateral posterior fossa. Results: Retrosigmoid craniotomies were performed on four latex-injected cadaver heads (eight CPAs). Microsurgical exposures were performed to identify neurovascular structures in each segment. 0° and 30° rigid endoscope lenses were subsequently introduced into each corridor and views were compared in this manner. The endoscopic images were compared with the standard microscopic views to determine the degree of visualization with each technique. In each case, better visualization was provided by both the 0° and 30° endoscope lenses. Endoscopic views frequently clarified neurovascular relationships in obscured anatomic regions. Conclusion: Endoscope-assisted microsurgery could allow better visualization of various regions of the posterior fossa. Surgical planning for posterior fossa lesions should include consideration of this combined approach.
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Affiliation(s)
- Mohammed A Fouda
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yasser Jeelani
- Department of Neurosurgery, Brigham and Woman's Hospital, Boston, Massachusetts.,Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | - Abdulkarim Gokoglu
- Department of Neurosurgery, Brigham and Woman's Hospital, Boston, Massachusetts
| | - Rajiv R Iyer
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alan R Cohen
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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5
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Magill ST, Lee YM, Rubio RR, Nguyen MP, Heilman CB, McDermott MW. Retrosigmoid Craniectomy with a Layered Soft Tissue Dissection and Hydroxyapatite Reconstruction: Technical Note, Surgical Video, Regional Anatomy, and Outcomes. Skull Base Surg 2021; 83:185-192. [DOI: 10.1055/s-0040-1721815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 09/03/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Introduction There are many reported modifications to the retrosigmoid approach including variations in skin incisions, soft tissue dissection, bone removal/replacement, and closure.
Objective The aim of this study was to report the technical nuances developed by two senior skull base surgeons for retrosigmoid craniectomy with reconstruction and provide anatomic dissections, surgical video, and outcomes.
Methods The regional soft tissue and bony anatomy as well as the steps for our retrosigmoid craniectomy were recorded with photographs, anatomic dissections, and video. Records from 2017 to 2019 were reviewed to determine the incidence of complications after the authors began using the described approach.
Results Dissections of the relevant soft tissue, vascular, and bony structures were performed. Key surgical steps are (1) a retroauricular C-shaped skin incision, (2) developing a skin and subgaleal tissue flap of equal thickness above the fascia over the temporalis and sub-occipital muscles, (3) creation of subperiosteal soft tissue planes over the top of the mastoid and along the superior nuchal line to expose the suboccipital region, (4) closure of the craniectomy defect with in-lay titanium mesh and overlay hydroxyapatite cranioplasty, and (5) reapproximation of the soft tissue edges during closure. Complications in 40 cases were pseudomeningocele requiring shunt (n = 3, 7.5%), wound infection (n = 1, 2.5%), and aseptic meningitis (n = 1, 2.5%). There were no incisional cerebrospinal fluid leaks.
Conclusion The relevant regional anatomy and a revised technique for retrosigmoid craniectomy with reconstruction have been presented with acceptable results. Readers can consider this technique when using the retrosigmoid approach for pathology in the cerebellopontine angle.
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Affiliation(s)
- Stephen T. Magill
- Department of Neurological Surgery, University of California, San Francisco, California, United States
| | - Young M. Lee
- Department of Neurological Surgery, University of California, San Francisco, California, United States
| | - Roberto R. Rubio
- Department of Neurological Surgery, University of California, San Francisco, California, United States
| | - Minh P. Nguyen
- Department of Neurological Surgery, University of California, San Francisco, California, United States
| | - Carl B. Heilman
- Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts, United States
| | - Michael W. McDermott
- Department of Neurological Surgery, University of California, San Francisco, California, United States
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Wang M, Chae R, Shehata J, Vigo V, Raygor KP, Tomasi SO, McDermott MW, Abla AA, El-Sayed IH, Rodriguez Rubio R. Comparative analysis of surgical exposure and freedom between the subtonsillar, endoscope-assisted subtonsillar, and far-lateral approaches to the lower clivus: A cadaveric study. J Clin Neurosci 2020; 72:412-419. [PMID: 31937496 DOI: 10.1016/j.jocn.2019.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 10/12/2019] [Accepted: 11/18/2019] [Indexed: 11/19/2022]
Abstract
The far-lateral (FL)approach is a classic technique for skull base surgeries involving the lower clivus (LC).Recently, a modified suboccipital midline approach known as the subtonsillar (ST) approach, along with the endoscope-assisted subtonsillar (EST) approach, has been described as a minimally invasive technique to treat LC lesions. However, there is no quantitative study on comparing these approaches together for reaching LC. We aimed to compare surgical exposure and freedom provided by ST, EST, and FL approaches for various targets at LC. These approaches were performed on each side of five cadaveric specimens (total 10 sides), and relevant parameters were quantified and compared using a repeated measures ANOVA test. FL approach yielded the greatest surgical area (237.8 ± 56.0 mm2) and exposure, including lengths of glossopharyngeal nerve (16.2 ± 1.9 mm), hypoglossal nerve (11.4 ± 2.4 mm), vertebral artery (23.9 ± 3.3 mm), followed by EST and ST approaches. For surgical freedom, FL approach provided the greatest angle of attack (90.0 ± 14.0° at jugular foramen, 95.1 ± 15.8° at hypoglossal canal, 83.4 ± 31.4° at bifurcation point of posterior inferior cerebellar artery and vertebral artery). Our systematic comparison suggests that EST approach, compared to ST approach, can significantly increase surgical exposure to the medial side of LC, but FL approach still provides the greatest surgical exposure and freedom at LC. Despite the limitations of a cadaveric study, our quantitative data can update the literature on currently available surgical techniques for reaching LC and better inform preoperative planning in this area. Further studies should be performed to evaluate these approaches in clinical practice.
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Affiliation(s)
- Minghao Wang
- Department of Neurosurgery, First Affiliated Hospital of China Medical University, Shenyang, China; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, CA, USA
| | - Ricky Chae
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, CA, USA; Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Joseph Shehata
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, CA, USA; Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Vera Vigo
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, CA, USA; Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Santino Ottavio Tomasi
- Department of Neurosurgery, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Michael W McDermott
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Adib A Abla
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, CA, USA; Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Ivan H El-Sayed
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, CA, USA; Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, CA, USA
| | - Roberto Rodriguez Rubio
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, CA, USA; Department of Neurological Surgery, University of California, San Francisco, CA, USA; Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, CA, USA. http://skullbaselab.ucsf.edu
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7
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Corrivetti F, Cacciotti G, Scavo CG, Roperto R, Stati G, Sufianov A, Mastronardi L. Flexible endoscopic assistance in the surgical management of vestibular schwannomas. Neurosurg Rev 2019; 44:363-371. [PMID: 31768695 DOI: 10.1007/s10143-019-01195-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/13/2019] [Accepted: 10/02/2019] [Indexed: 11/24/2022]
Abstract
Endoscopic-assisted techniques have extensively been applied to vestibular schwannoma (VS) surgery allowing to increase the extent of resection, minimize complications, and preserve facial nerve and auditory functions. In this paper, we retrospectively analyze the effectiveness of flexible endoscope in the endoscopic-assisted retrosigmoid approach for the surgical management of VS of various sizes. The authors conducted a retrospective analysis on 32 patients who underwent combined microscopic and flexible endoscopic resection of VS of various sizes over a period of 16 months. Flexible endoscopic-assisted retrosigmoid approach was performed in all cases, and in 6 cases, flexible and rigid endoscopic control were used in combination to evaluate the differences between the two surgical instruments. The surgical results were additionally compared with a previous case series of 141 patients operated for VS of various sizes without endoscopic assistance. Gross-total resection was achieved in 84% of the cases and near-total resection was accomplished in the rest of them. Excellent or good facial nerve function was observed in all except one case with a preoperative severe facial palsy. Hearing preservation surgery (HPS) was attempted in 11 cases and accomplished in 9 (81.8%). A tumor remnant was endoscopically identified in the fundus of the IAC in all cases (100%). Endoscopic assistance increased the rate of total removal and no intrameatal residual tumor was seen at radiological follow-up. Comparative analysis with a surgical cohort of patients operated with the sole microsurgical technique showed a significative association between endoscopic assistance and intracanalicular extent of resection. Combined microsurgical and flexible endoscopic assistance provides remarkable advantages in the pursuit of maximal safe resection of VS and preservation of facial nerve and auditory functions, minimizing the risk of post-operative complications.
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Affiliation(s)
- Francesco Corrivetti
- Division of Neurosurgery, Department of Surgical Specialties, San Filippo Neri Hospital/ASL, 1, Roma, Roma, Italy
| | - Guglielmo Cacciotti
- Division of Neurosurgery, Department of Surgical Specialties, San Filippo Neri Hospital/ASL, 1, Roma, Roma, Italy
| | - Carlo Giacobbo Scavo
- Division of Neurosurgery, Department of Surgical Specialties, San Filippo Neri Hospital/ASL, 1, Roma, Roma, Italy
| | - Raffaelino Roperto
- Division of Neurosurgery, Department of Surgical Specialties, San Filippo Neri Hospital/ASL, 1, Roma, Roma, Italy
| | - Giovanni Stati
- Division of Neurosurgery, Department of Surgical Specialties, San Filippo Neri Hospital/ASL, 1, Roma, Roma, Italy
| | - Albert Sufianov
- Federal Centre of Neurosurgery, Tyumen, Russian Federation.,Department of Neurosurgery, The State Education Institution of Higher Professional Training, The First Sechenov Moscow State Medical University under Ministry of Health, Moscow, Russian Federation
| | - Luciano Mastronardi
- Division of Neurosurgery, Department of Surgical Specialties, San Filippo Neri Hospital/ASL, 1, Roma, Roma, Italy. .,Department of Neurosurgery, The State Education Institution of Higher Professional Training, The First Sechenov Moscow State Medical University under Ministry of Health, Moscow, Russian Federation.
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8
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Godano U. Posterior fossa endoscopy: a commentary. J Neurosurg Sci 2019; 64:492-494. [PMID: 31601064 DOI: 10.23736/s0390-5616.19.04765-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Umberto Godano
- Unit of Neurosurgery, Maria Cecilia Hospital, Cotignola di Lugo, Ravenna, Italy -
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9
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Kurucz P, Ganslandt O, Buchfelder M, Barany L. Arachnoid Membranes Around the Cisternal Segment of the Trigeminal Nerve: A Cadaveric Anatomic Study and Intraoperative Observations During Minimally Invasive Microvascular Decompression Surgery. World Neurosurg 2019; 125:e262-e272. [DOI: 10.1016/j.wneu.2019.01.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/03/2019] [Accepted: 01/05/2019] [Indexed: 10/27/2022]
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10
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Endoscope-Assisted Microvascular Decompression for the Management of Hemifacial Spasm Caused by Vertebrobasilar Dolichoectasia. World Neurosurg 2019; 121:e566-e575. [DOI: 10.1016/j.wneu.2018.09.166] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/20/2018] [Accepted: 09/21/2018] [Indexed: 11/21/2022]
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11
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Lan Z, Richard SA, Chen M, Yang C. Endoscopically assisted supratentorial evacuation of infratentorial epidural hematomas crossing the transverse sinus. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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12
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Belykh E, Onaka NR, Zhao X, Cavallo C, Yağmurlu K, Lei T, Byvaltsev VA, Preul MC, Nakaji P. Endoscopically Assisted Targeted Keyhole Retrosigmoid Approaches for Microvascular Decompression: Quantitative Anatomic Study. World Neurosurg 2018; 119:e1-e15. [PMID: 29960095 DOI: 10.1016/j.wneu.2018.04.218] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/26/2018] [Accepted: 04/27/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We describe and quantitatively assess minimally invasive keyhole retrosigmoid approaches targeted to the upper, middle, and lower cranial nerve (CN) complexes of the cerebellopontine angle (CPA). METHODS Anatomic dissections were performed on 10 sides of 5 fixed, silicone-injected cadaver heads. Surgical views through various trajectories were assessed in endoscopic videos and 3-dimensional (3D) interactive virtual reality microscope views. Surgical freedom and angles of attack to the proximal and distal areas of CN complexes of the CPA were compared among upper and lower keyholes and conventional retrosigmoid craniotomy using neuronavigation. RESULTS Compared with keyholes, the conventional approach had superior surgical freedom to most areas except for the distal CN V, the root of CN VII, and the root of CN IX, where differences were not significant. The conventional retrosigmoid approach provided a larger horizontal angle of attack than either the upper or lower keyholes for all selected areas; however, the vertical angles of attack were not different. Splitting the petrosal fissure resulted in a significant increase in the vertical angle of attack to the root zones of CNs V and VII but not to the distal areas of these nerves or CN IX. Illustrative cases of endoscope-assisted keyhole retrosigmoid approaches for the treatment of trigeminal neuralgia, hemifacial spasm, and glossopharyngeal neuralgia are presented. CONCLUSIONS Targeted keyhole retrosigmoid approaches require detailed understanding of the 3D anatomy of the CPA to create appropriate locations of corridors, including skin incisions and keyholes. Endoscope assistance complements the standard microsurgical technique by maximizing the visualization and identification of the delicate neurovascular structures.
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Affiliation(s)
- Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Naomi R Onaka
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Xiaochun Zhao
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kaan Yağmurlu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ting Lei
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Vadim A Byvaltsev
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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13
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Corrivetti F, Cacciotti G, Giacobbo Scavo C, Roperto R, Mastronardi L. Flexible Endoscopic-Assisted Microsurgical Radical Resection of Intracanalicular Vestibular Schwannomas by a Retrosigmoid Approach: Operative Technique. World Neurosurg 2018; 115:229-233. [PMID: 29704694 DOI: 10.1016/j.wneu.2018.04.108] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 04/14/2018] [Accepted: 04/16/2018] [Indexed: 11/26/2022]
Abstract
The efficacy of endoscopic techniques in the surgical management of intracanalicular vestibular schwannomas (ICVSs) has been underlined in recent studies. An endoscopic- assisted retrosigmoid approach (EARSA) appears to be particularly suitable for achieving complete resection of an ICVS. In this study, we describe the surgical treatment of 3 cases of ICVS with an EARSA, highlighting the advantages and limitations of flexible endoscopy in accomplishing a safe radical resection with hearing preservation. Three patients with an ICVS underwent surgery via a flexible endoscopic-assisted microneurosurgical retrosigmoid approach. Flexible endoscopic assistance allowed the identification of residual tumor located in the most lateral portion of the fundus of the internal auditory canal in all cases. Endoscopic controls and further microsurgical resection were attempted, and complete surgical resection was achieved in all cases without the occurrence of postoperative facial or auditory nerve dysfunction. Flexible endoscopy appears to be particularly useful and safe in the surgical management of ICVS by microneurosurgery via an EARSA.
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Affiliation(s)
- Francesco Corrivetti
- Division of Neurosurgery, Department of Surgical Specialties, San Filippo Neri Hospital/ASL Roma 1, Rome, Italy
| | - Guglielmo Cacciotti
- Division of Neurosurgery, Department of Surgical Specialties, San Filippo Neri Hospital/ASL Roma 1, Rome, Italy
| | - Carlo Giacobbo Scavo
- Division of Neurosurgery, Department of Surgical Specialties, San Filippo Neri Hospital/ASL Roma 1, Rome, Italy
| | - Raffaelino Roperto
- Division of Neurosurgery, Department of Surgical Specialties, San Filippo Neri Hospital/ASL Roma 1, Rome, Italy
| | - Luciano Mastronardi
- Division of Neurosurgery, Department of Surgical Specialties, San Filippo Neri Hospital/ASL Roma 1, Rome, Italy.
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Barany L, Baksa G, Patonay L, Racz G, Ganslandt O, Buchfelder M, Kurucz P. Primary Obstruction of the Foramen of Luschka: Anatomy, Histology, and Clinical Significance. World Neurosurg 2018; 112:e288-e297. [PMID: 29339320 DOI: 10.1016/j.wneu.2018.01.037] [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: 11/23/2017] [Revised: 01/03/2018] [Accepted: 01/05/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND The foramen of Luschka is a natural aperture between the fourth ventricle and the subarachnoid space at the cerebellopontine angle. Membranous closure of this foramen is referred to as primary obstruction. Available information about this variant and its role in the development of the cysts of the posterior fossa is contradictory. METHODS The macroscopic and histologic features of the obstructed foramina were examined in 61 formalin-fixed human brains (122 foramina). Three rhomboid lips of various sizes with lateral recess were used for comparison. Five postoperative cases of diverticulum of the foramen of Luschka were included in this study, with 1 case presented in detail to illustrate anatomic and histologic findings. RESULTS Primary obstruction was present in 11 of 122 cases. In 1 case, an enlarged rigid pouch with a thick wall was found. The wall of the membrane in primary obstruction and the rhomboid lip were composed of an inner ependymal, a middle glial, and an outer leptomeningeal layer. CONCLUSIONS The rhomboid lip is a remnant of the roof of the fourth ventricle. Imperforation of the foramen of Luschka results in a pouch in the cerebellopontine angle that contains choroid plexus (Bochdalek's flower basket) and communicates with the fourth ventricle. This pouch has the potential to grow to a diverticulum and cause clinical symptoms. Based on our clinical observations, detailed radiologic and surgical-anatomic criteria were proposed to support the differential diagnosis of a diverticulum of the foramen of Luschka. Treatment strategies were also suggested.
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Affiliation(s)
- Laszlo Barany
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary.
| | - Gabor Baksa
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary
| | - Lajos Patonay
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary
| | - Gergely Racz
- 1(st) Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Oliver Ganslandt
- Department of Neurosurgery, Klinikum Stuttgart, Stuttgart, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Peter Kurucz
- Department of Neurosurgery, Klinikum Stuttgart, Stuttgart, Germany; Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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