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Plata-Bello J, Mosteiro-Cadaval A, Manfrellotti R, Torné R, Perelló MA, Prats-Galino A, Di Somma A, Enseñat J. The Endoscopic Transorbital Approach for Vascular Surgery: An Anterior Circulation Anatomic Study, 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01242. [PMID: 38967432 DOI: 10.1227/ons.0000000000001254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/08/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Minimally invasive endoscopic approaches in cranial base surgery have been developing in the past decades. The transorbital (TO) route is one promising alternative, yet its adequacy for intracranial vascular lesions remains unclear. The present anatomic work aimed to test the feasibility and to provide a qualitative description of the endoscopic TO approach for the anterior circulation, namely the internal carotid artery and the middle cerebral artery. METHODS Seven embalmed adult cadaveric specimens (12 sides) were used in the study. Each side was approached in 3 successive steps: (1) Superior-eyelid TO approach, with great and lesser sphenoid wing removal. (2) Removal of anterior clinoid process (ACP). (3) Removal of the lateral orbital rim. All the procedures were performed under endoscopic view. RESULTS The TO approach without removing the ACP allowed to dissect the sphenoidal and lateral segments of the Sylvian fissure with an adequate identification of the middle cerebral artery bifurcation in all specimens. The removal of the ACP allowed further dissection toward the opticocarotid cistern, with the identification of the ophthalmic, posterior communicating, and the anterior choroidal arteries. The internal carotid artery bifurcation and A1 segment were also readily identified. Finally, removal of the lateral orbital rim provided a wider and more comfortable access to the above-mentioned vascular structures. CONCLUSION According to our anatomic data, the TO approach can be used to reach the main vascular components of the anterior circulation. This opens the field for exploring its application in the treatment of vascular pathology, particularly aneurysms.
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Affiliation(s)
- Julio Plata-Bello
- Department of Neurosurgery, Hospital Universitario de Canarias, Tenerife, Spain
| | | | - Roberto Manfrellotti
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Ramón Torné
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
- Clinical Neurophysiology Research Group, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alberto Di Somma
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
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Mariniello G, Corvino S, Corazzelli G, de Divitiis O, Fusco G, Iuliano A, Strianese D, Briganti F, Elefante A. Spheno-Orbital Meningiomas: The Rationale behind the Decision-Making Process of Treatment Strategy. Cancers (Basel) 2024; 16:2148. [PMID: 38893267 PMCID: PMC11171661 DOI: 10.3390/cancers16112148] [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: 05/15/2024] [Revised: 05/27/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
Surgery stands as the primary treatment for spheno-orbital meningiomas, following a symptoms-oriented approach. We discussed the decision-making process behind surgical strategies through a review of medical records from 80 patients who underwent surgical resection at the University of Naples Federico II. Different surgical approaches were employed based on the tumor's location relative to the optic nerve's long axis, categorized into lateral (type I), medial (type II), and diffuse (type III). We examined clinical, neuroradiological, surgical, pathological, and outcome factors. Proptosis emerged as the most frequent symptom (97%), followed by visual impairment (59%) and ocular motility issues (35%). Type I represented 20%, type II 43%, and type III 17%. Growth primarily affected the optic canal (74%), superior orbital fissure (65%), anterior clinoid (60%), and orbital apex (59%). The resection outcomes varied, with Simpson grades I and II achieved in all type I cases, 67.5% of type II, and 18% of type III. Recurrence rates were highest in type II (41.8%) and type III (59%). Improvement was notable in proptosis (68%) and visual function (51%, predominantly type I). Surgery for spheno-orbital meningiomas should be tailored to each patient, considering individual characteristics and tumor features to improve quality of life by addressing primary symptoms like proptosis and visual deficits.
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Affiliation(s)
- Giuseppe Mariniello
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (G.M.); (S.C.); (G.C.); (O.d.D.)
| | - Sergio Corvino
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (G.M.); (S.C.); (G.C.); (O.d.D.)
| | - Giuseppe Corazzelli
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (G.M.); (S.C.); (G.C.); (O.d.D.)
| | - Oreste de Divitiis
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (G.M.); (S.C.); (G.C.); (O.d.D.)
| | - Giancarlo Fusco
- Department of Advanced Biomedical Sciences, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (G.F.); (F.B.)
| | - Adriana Iuliano
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Ophthalmology, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (A.I.); (D.S.)
| | - Diego Strianese
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Ophthalmology, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (A.I.); (D.S.)
| | - Francesco Briganti
- Department of Advanced Biomedical Sciences, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (G.F.); (F.B.)
| | - Andrea Elefante
- Department of Advanced Biomedical Sciences, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy; (G.F.); (F.B.)
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Corvino S, Maiuri F. Letter to the editor regarding "Predictive factors of the postoperative proptosis recovery in surgery of spheno-orbital meningiomas". Acta Neurochir (Wien) 2024; 166:242. [PMID: 38816513 DOI: 10.1007/s00701-024-06141-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 04/20/2024] [Indexed: 06/01/2024]
Affiliation(s)
- Sergio Corvino
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, University "Federico II" of Naples, Naples, 80131, Italy.
| | - Francesco Maiuri
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, University "Federico II" of Naples, Naples, 80131, Italy
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Plata-Bello J, Mosteiro-Cadaval A, Torné R, Di Somma A, Enseñat J, Prats-Galino A. Optimizing the Endoscopic Transorbital Approach: MacCarty Keyhole for Enhanced Surgical Exposure in the Opticocarotid Region. World Neurosurg 2024; 185:290-296. [PMID: 38453005 DOI: 10.1016/j.wneu.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/01/2024] [Accepted: 03/02/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND In recent years, the endoscopic transorbital (TO) approach has gained increasing interest for the treatment of middle cranial fossa lesions. We propose a technical refinement to the conventional superior eyelid TO approach, which improves the surgical exposure and augments the working angles when targeting the opticocarotid region. METHODS Four embalmed adult cadaveric specimens (8 sides) were dissected at the Laboratory of Surgical Neuroanatomy of our institution. A TO approach was performed, with removal of the anterior clinoid process and the lateral orbital rim. Subsequently, the MacCarty keyhole was drilled in the superolateral orbital wall. Given that the lesser sphenoid wing was already drilled in the conventional TO craniectomy, the opening of the keyhole was essentially a lateral extension of the craniectomy. RESULTS The procedure was successfully conducted in all 4 orbits. Clinoidectomy was performed either before or after extending the craniectomy to the MacCarty point. Extending the craniectomy made anterior clinoidectomy easier, by increasing the surgical exposure, and allowing a more lateral entrance for the endoscope. The extension also facilitated frontal lobe retraction, and it facilitated the optic nerve and carotid artery manipulation. Postoperative computed tomography scans showed a minimal 10-mm craniectomy extension, which remained covered by the temporal muscle after reconstruction. CONCLUSIONS The modified endoscopic TO approach with the extension of the craniectomy to MacCarty point improves surgical access and visualization of the opticocarotid region. This facilitates anterior clinoidectomy and optic nerve decompression. Although it implies judicious instrument manipulation and a larger incision size, further studies can define its potential benefits.
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Affiliation(s)
- Julio Plata-Bello
- Department of Neurosurgery, Hospital Universitario de Canarias, Tenerife, Spain
| | | | - Ramón Torné
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alberto Di Somma
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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Zoia C, Maiorano E, Borromeo S, Mantovani G, Spena G, Pagella F. Endoscopic approaches to the orbit: Transnasal and transorbital, a retrospective case series. BRAIN & SPINE 2024; 4:102770. [PMID: 38510598 PMCID: PMC10951755 DOI: 10.1016/j.bas.2024.102770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/18/2024] [Indexed: 03/22/2024]
Abstract
Introduction Orbital pathologies requiring surgery are traditionally treated by open approach with different techniques depending on the lesion location. Recently, minimally invasive endoscopic approaches, such as the Endoscopic Endonasal Approach (EEA) and the Endoscopic Transorbital Approach (ETA) have been introduced in orbital surgery. Research question The purpose of this study is to report the combined experience of the Neurosurgical and Ear-Nose-Throat (ENT) Units in the endoscopic approach of orbital pathologies. Material and methods We retrospectively retrieved data on patients treated at our Institution between 2016 and 2021 with endoscopic approach for orbital pathologies. The Clavien-Dindo classification and the Scar Cosmesis Assessment and Rating (SCAR) Scale have been used to assess complications and cosmetic outcomes. Results 39 patients met the inclusion criteria. EEA (15 patients) or ETA (20 patients) were chosen to approach the lesions. In three cases we used a combination of endoscopic and anterior orbitotomy and in one patient a combination of EEA + ETA. The type of procedure performed was orbital biopsy (9 cases), orbital decompression (6 cases), subtotal resection of the lesion (STR) (8 cases) and total resection of the lesion (GTR) (16 cases). The more frequent postoperative complications were diplopia (5.1%, with 1 case of permanent diplopia), trigeminal paraesthesia and dysesthesia (5.1%), palpebral edema (17.9%), periorbital ecchymosis (7.7%). Mean follow up time was 21 months (range 2-63 months). Discussion and conclusion Endoscopic approaches to orbital compartments provide minimally invasive access to every orbital compartment with low complications rate and good cosmetic outcome.
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Affiliation(s)
- Cesare Zoia
- Neurosurgery Unit, Moriggia Pelascini Hospital, Gravedona e Uniti, Italy
| | - Eugenia Maiorano
- Department of Surgical Science, University of Pavia, Pavia, Italy
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Sara Borromeo
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Giorgio Mantovani
- Neurosurgery Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Giannantonio Spena
- Neurosurgery Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Fabio Pagella
- Department of Surgical Science, University of Pavia, Pavia, Italy
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
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Locatelli D, Veiceschi P, Arosio AD, Agosti E, Peris-Celda M, Castelnuovo P. 360 Degrees Endoscopic Access to and Through the Orbit. Adv Tech Stand Neurosurg 2024; 50:231-275. [PMID: 38592533 DOI: 10.1007/978-3-031-53578-9_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
The treatment of pathologies located within and surrounding the orbit poses considerable surgical challenges, due to the intricate presence of critical neurovascular structures in such deep, confined spaces. Historically, transcranial and craniofacial approaches have been widely employed to deal with orbital pathologies. However, recent decades have witnessed the emergence of minimally invasive techniques aimed at reducing morbidity. Among these techniques are the endoscopic endonasal approach and the subsequently developed endoscopic transorbital approach (ETOA), encompassing both endonasal and transpalpebral approaches. These innovative methods not only facilitate the management of intraorbital lesions but also offer access to deep-seated lesions within the anterior, middle, and posterior cranial fossa via specific transorbital and endonasal corridors. Contemporary research indicates that ETOAs have demonstrated exceptional outcomes in terms of morbidity rates, cosmetic results, and complication rates. This study aims to provide a comprehensive description of endoscopic-assisted techniques that enable a 360° access to the orbit and its surrounding regions. The investigation will delve into indications, advantages, and limitations associated with different approaches, while also drawing comparisons between endoscopic approaches and traditional microsurgical transcranial approaches.
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Affiliation(s)
- Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
- Head and Neck and Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Research Center for Pituitary Adenoma and Sellar Pathology, University of Insubria, Varese, Italy
| | - Pierlorenzo Veiceschi
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
| | - Alberto Daniele Arosio
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
- Unit of Neurosurgery, Spedali Civili Hospital, Brescia, Italy
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Paolo Castelnuovo
- Head and Neck and Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Research Center for Pituitary Adenoma and Sellar Pathology, University of Insubria, Varese, Italy
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, "Ospedale di Circolo e Fondazione Macchi", University of Insubria, Varese, Italy
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Zoia C, Mastantuoni C, Solari D, de Notaris M, Corrivetti F, Spena G, Cavallo LM. Transorbital and supraorbital uniportal multicorridor approach to the orbit, anterior, middle and posterior cranial fossa: Anatomic study. BRAIN & SPINE 2023; 4:102719. [PMID: 38163002 PMCID: PMC10753433 DOI: 10.1016/j.bas.2023.102719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/21/2023] [Accepted: 11/25/2023] [Indexed: 01/03/2024]
Abstract
Introduction The transorbital route has been proposed for addressing orbital and paramedian skull base lesions. It can be complemented by further marginotomies, as per "extended-transorbital approach" and combined with others ventro-basal approaches featuring the concept of "multiportal surgery". Nevertheless, it cannot address some anatomical regions like the clinoid, carotid bifurcation and the Sylvian fissure. Therefore, we propose a combined transorbital and a supraorbital approach, attainable by a single infra-brow incision, and we called it "Uniportal multicorridor" approach. Research question The aim of our study is to verify its feasibility and deep anatomical targets through a cadaveric study. Materials and methods Anatomic dissections were performed at the Laboratory of ICLO Teaching and Research Center (Verona, Italy) on four formalin-fixed cadaveric heads injected with colored neoprene latex (8 sides). A stepwise dissection of the supraorbital and transorbital approaches (with an infra-brow skin incision) to the anterior tentorial incisura, clinoid area, lateral wall of the cavernous sinus, middle temporal fossa, posterior fossa, and Sylvian fissure is described. Results We analyzed the anatomic areas reached by the transorbital corridor dividing them as follow: lateral wall of the cavernous sinus, middle temporal fossa, posterior fossa, and Sylvian fissure; while the anatomic areas addressed by the supraorbital craniotomy were the clinoid area and the anterior tentorial incisura. Conclusions The described uniportal multi-corridor approach combines a transorbital corridor and a supraorbital craniotomy, providing a unique intra and extradural control over the anterior, middle, and posterior fossa, tentorial incisura and the Sylvian fissure, via an infra-brow skin incision.
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Affiliation(s)
- Cesare Zoia
- UOC Neurochirurgia, Ospedale Moriggia Pelascini, Gravedona, Italy
| | - Ciro Mastantuoni
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita Degli Studi di Napoli Federico II, Naples, Italy
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita Degli Studi di Napoli Federico II, Naples, Italy
| | - Matteo de Notaris
- Department of Neuroscience, Neurosurgery Operative Unit, “San Pio” Hospital, Benevento, Italy
- Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy
| | - Francesco Corrivetti
- Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy
| | | | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Universita Degli Studi di Napoli Federico II, Naples, Italy
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Tran AQ, Maniar A, Tooley AA, North VS, Sisti MB, Kazim M. Spheno-Orbital Meningioma - Treatment Outcomes and Factors Influencing Recurrence. Ophthalmic Plast Reconstr Surg 2023; 39:570-578. [PMID: 37133386 DOI: 10.1097/iop.0000000000002403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
PURPOSE To determine treatment outcomes, recurrence rates, and predictors of recurrence, to inform future therapeutic approaches for spheno-orbital meningiomas (SOM). METHODS A retrospective single-center study of SOM treated from 1990 to 2021 was conducted with comprehensive neuro-ophthalmologic follow-up at Columbia University Medical Center (CUMC). Recurrence requiring reintervention was defined clinically as worsening of visual acuity, visual field defect, or ocular motility after an initial period of stabilization or 6 months of improvement following treatment, or radiologically as either a regrowth with an increase in tumor size by 20% at the site of previous growth or a new region of tumor growth. RESULTS In total 46 patients met the inclusion criteria. The mean follow-up was 106 months (range 1-303). Dictated by the phenotype of the disease, patients underwent either gross- (50%), near- (17%), or subtotal resection (26%). Removal of the anterior clinoid process (ACP) was performed in 52% of patients. Nine patients (20%) required an enucleation or exenteration. Radiotherapy was employed at some point of treatment in 50% of cases. Inherited cases (24%) were referred to CUMC for treatment following 1 or more recurrences. The total recurrence rate, including inherited cases, was 54%, occurring at a mean interval of 43 months. The recurrence rate of patients treated solely at CUMC was 40%, occurring at a mean interval of 41 months. A subset of patients (32%) had 2 or more recurrences. Histopathology at the first surgery was WHO grade I (87%) and II (13%) and at the final surgery was WHO grade I (74%), II (21%), and III (4%). A subset of grade I tumors that received radiotherapy (35%) evolved to a higher grade or developed multiple recurrences without a change in histologic grade I. Grade II tumors and treatment with radiotherapy increased the odds of recurrence. Removal of the ACP and gross total resection decreased the odds of recurrence. CONCLUSION Due to the routinely long interval to tumor recurrence, lifelong surveillance of patients with SOM is prudent. ACP resection and gross total resection, where possible, reduce tumor recurrence and the need for further treatment. Radiotherapy should be reserved for higher-grade meningiomas and select grade I tumors.
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Affiliation(s)
- Ann Q Tran
- Oculoplastic and Orbital Surgery, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY
- Department of Ophthalmology, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL
| | - Arpita Maniar
- Oculoplastic and Orbital Surgery, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY
| | | | - Victoria S North
- Oculoplastic and Orbital Surgery, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY
- Department of Ophthalmology, Tufts Medical Center, Boston, MA
| | - Michael B Sisti
- Department of Ophthalmology, Mayo Clinic, Rochester, MN
- Department of Neurosurgery, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY
| | - Michael Kazim
- Oculoplastic and Orbital Surgery, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY
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De Rosa A, Mosteiro A, Guizzardi G, Roldán P, Torales J, Matas Fassi J, Cavallo LM, Solari D, Prats-Galino A, Di Somma A, Enseñat J. Endoscopic transorbital resection of the temporal lobe: anatomic qualitative and quantitative study. Front Neuroanat 2023; 17:1282226. [PMID: 37818154 PMCID: PMC10560990 DOI: 10.3389/fnana.2023.1282226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/30/2023] [Indexed: 10/12/2023] Open
Abstract
Objective Starting from an anatomic study describing the possibility of reaching the temporal region through an endoscopic transorbital approach, many clinical reports have now demonstrated the applicability of this strategy when dealing with intra-axial lesions. The study aimed to provide both a qualitative anatomic description of the temporal region, as seen through a transorbital perspective, and a quantitative analysis of the amount of temporal lobe resection achievable via this route. Material and methods A total of four cadaveric heads (eight sides) were dissected at the Laboratory of Surgical Neuroanatomy (LSNA) of the University of Barcelona, Spain. A stepwise description of the resection of the temporal lobe through a transorbital perspective is provided. Qualitative anatomical descriptions and quantitative analysis of the amount of the resection were evaluated by means of pre- and post-dissection CT and MRI scans, and three-dimensional reconstructions were made by means of BrainLab®Software. Results The transorbital route gives easy access to the temporal region, without the need for extensive bone removal. The resection of the temporal lobe proceeded in a subpial fashion, mimicking what happens in a surgical scenario. According to our quantitative analysis, the mean volume removed was 51.26%, with the most superior and lateral portion of the temporal lobe being the most difficult to reach. Conclusion This anatomic study provides qualitative and quantitative details about the resection of the temporal lobe via an endoscopic transorbital approach. Our results showed that the resection of more than half of the temporal lobe is possible through this surgical corridor. While the anterior, inferior, and mesial portions of the temporal lobe were easily accessible, the most superior and lateral segment was more difficult to reach and resect. Our study serves as an integration to the current anatomic knowledge and clinical practice knowledge highlighting and also as a starting point for further anatomic studies addressing more selected segments of the temporal lobe, i.e., the mesial temporal region.
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Affiliation(s)
- Andrea De Rosa
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | | | | | - Pedro Roldán
- Department of Neurosurgery, Hospital Clinic, Barcelona, Spain
| | - Jorge Torales
- Department of Neurosurgery, Hospital Clinic, Barcelona, Spain
| | - Jessica Matas Fassi
- Department of Ophthalmology, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clinic, Barcelona, Spain
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Serioli S, Nizzola M, Plou P, De Bonis A, Meyer J, Leonel LCPC, Tooley AA, Wagner LH, Bradley EA, Van Gompel JJ, Benini ME, Dallan I, Peris-Celda M. Surgical Anatomy of the Microscopic and Endoscopic Transorbital Approach to the Middle Fossa and Cavernous Sinus: Anatomo-Radiological Study with Clinical Applications. Cancers (Basel) 2023; 15:4435. [PMID: 37760405 PMCID: PMC10527149 DOI: 10.3390/cancers15184435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The transorbital approaches (TOAs) have acquired growing notoriety, thanks to their ability to offer alternative corridors to the skull base. However, the limited access and the unfamiliarity with this surgical perspective make recognition of key landmarks difficult, especially for less experienced surgeons. The study wants to offer a detailed description of the anatomy to comprehend the potential and limitations of TOAs. METHODS Measurements of the orbit region and the surrounding areas were performed on two hundred high-resolution CT scans and thirty-nine dry skulls. Five specimens were dissected to illustrate the TOA, and one was used to perform the extradural clinoidectomy. Three clinical cases highlighted the surgical applications. RESULTS A step-by-step description of the key steps of the TOA was proposed and a comparison with the transcranial anterior clinoidectomy was discussed. The mean work distance was 6.1 ± 0.4 cm, and the lateral working angle increased 20 ± 5.4° after removing the lateral orbital rim. CONCLUSIONS TOAs are indicated in selected cases when tumor involves the lateral portion of the cavernous sinus or the middle skull base, obtaining a direct decompression of the optic nerve and avoiding excessive manipulation of the neurovascular structures. Comprehension of surgical anatomy of the orbit and its surrounding structures is essential to safely perform these approaches.
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Affiliation(s)
- Simona Serioli
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy;
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Mariagrazia Nizzola
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, 20132 Milan, Italy
| | - Pedro Plou
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Neurosurgery Department, Hospital Italiano de Buenos Aires, Buenos Aires C1199, Argentina
| | - Alessandro De Bonis
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, 20132 Milan, Italy
| | - Jenna Meyer
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Neurologic Surgery, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Luciano C. P. C. Leonel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Andrea A. Tooley
- Department of Ophthalmology, Mayo Clinic, Rochester, MN 55905, USA; (A.A.T.); (L.H.W.); (E.A.B.)
| | - Lilly H. Wagner
- Department of Ophthalmology, Mayo Clinic, Rochester, MN 55905, USA; (A.A.T.); (L.H.W.); (E.A.B.)
| | - Elizabeth A. Bradley
- Department of Ophthalmology, Mayo Clinic, Rochester, MN 55905, USA; (A.A.T.); (L.H.W.); (E.A.B.)
| | - Jamie J. Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Maria Elena Benini
- Department of Neurosurgery—Head and Neck Surgery, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy;
| | - Iacopo Dallan
- Department of Otolaryngology—Head and Neck Surgery, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy;
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN 55905, USA; (M.N.); (P.P.); (A.D.B.); (J.M.); (L.C.P.C.L.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Otolaryngology/Head and Neck Surgery, Mayo Clinic, Rochester, MN 55905, USA
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11
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Corvino S, Armocida D, Offi M, Pennisi G, Burattini B, Mondragon AV, Esposito F, Cavallo LM, de Notaris M. The anterolateral triangle as window on the foramen lacerum from transorbital corridor: anatomical study and technical nuances. Acta Neurochir (Wien) 2023; 165:2407-2419. [PMID: 37479917 PMCID: PMC10477108 DOI: 10.1007/s00701-023-05704-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/25/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE Neurosurgical indications for the superior eyelid transorbital endoscopic approach (SETOA) are rapidly expanding over the last years. Nevertheless, as any new technique, a detailed knowledge of the anatomy of the surgical target area, the operative corridor, and the specific surgical landmark from this different perspective is required for a safest and successful surgery. Therefore, the aim of this study is to provide, through anatomical dissections, a detailed investigation of the surgical anatomy revealed by SETOA via anterolateral triangle of the middle cranial fossa. We also sought to define the relevant surgical landmarks of this operative corridor. METHODS Eight embalmed and injected adult cadaveric specimens (16 sides) underwent dissection and exposure of the cavernous sinus and middle cranial fossa via superior eyelid endoscopic transorbital approach. The anterolateral triangle was opened and its content exposed. An extended endoscopic endonasal trans-clival approach (EEEA) with exposure of the cavernous sinus content and skeletonization of the paraclival and parasellar segments of the internal carotid artery (ICA) was also performed, and the anterolateral triangle was exposed. Measurements of the surface area of this triangle from both surgical corridors were calculated in three head specimens using coordinates of its borders under image-guide navigation. RESULTS The drilling of the anterolateral triangle via SETOA unfolds a space that can be divided by the course of the vidian nerve into two windows, a wider "supravidian" and a narrower "infravidian," which reveal different anatomical corridors: a "medial supravidian" and a "lateral supravidian," divided by the lacerum segment of the ICA, leading to the lower clivus, and to the medial aspect of the Meckel's cave and terminal part of the horizontal petrous ICA, respectively. The infravidian corridor leads medially into the sphenoid sinus. The arithmetic means of the accessible surface area of the anterolateral triangle were 45.48 ± 3.31 and 42.32 ± 2.17 mm2 through transorbital approach and endonasal approach, respectively. CONCLUSION SETOA can be considered a minimally invasive route complementary to the extended endoscopic endonasal approach to the anteromedial aspect of the Meckel's cave and the foramen lacerum. The lateral loop of the trigeminal nerve represents a reliable surgical landmark to localize the lacerum segment of the ICA from this corridor. Nevertheless, as any new technique, a learning curve is needed, and the clinical feasibility should be proven.
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Affiliation(s)
- Sergio Corvino
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, 80131, Naples, Italy.
- PhD Program in Neuroscience, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, 80131, Naples, Italy.
| | - Daniele Armocida
- Neurosurgery Division, Human Neurosciences Department, "Sapienza" University, 00185, Rome, Italy
| | - Martina Offi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy - Division of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Giovanni Pennisi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy - Division of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Benedetta Burattini
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy - Division of Neurosurgery, Catholic University of Rome, Rome, Italy
| | | | - Felice Esposito
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, 80131, Naples, Italy
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, 80131, Naples, Italy
| | - Matteo de Notaris
- Department of Neuroscience, Neurosurgery Operative Unit, "San Pio" Hospital, 82100, Benevento, Italy
- Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy
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12
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Corvino S, Villanueva-Solórzano PL, Offi M, Armocida D, Nonaka M, Iaconetta G, Esposito F, Cavallo LM, de Notaris M. A New Perspective on the Cavernous Sinus as Seen through Multiple Surgical Corridors: Anatomical Study Comparing the Transorbital, Endonasal, and Transcranial Routes and the Relative Coterminous Spatial Regions. Brain Sci 2023; 13:1215. [PMID: 37626571 PMCID: PMC10452901 DOI: 10.3390/brainsci13081215] [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: 07/05/2023] [Revised: 07/27/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Background: The cavernous sinus (CS) is a highly vulnerable anatomical space, mainly due to the neurovascular structures that it contains; therefore, a detailed knowledge of its anatomy is mandatory for surgical unlocking. In this study, we compared the anatomy of this region from different endoscopic and microsurgical operative corridors, further focusing on the corresponding anatomic landmarks encountered along these routes. Furthermore, we tried to define the safe entry zones to this venous space from these three different operative corridors, and to provide indications regarding the optimal approach according to the lesion's location. Methods: Five embalmed and injected adult cadaveric specimens (10 sides) separately underwent dissection and exposure of the CS via superior eyelid endoscopic transorbital (SETOA), extended endoscopic endonasal transsphenoidal-transethmoidal (EEEA), and microsurgical transcranial fronto-temporo-orbito-zygomatic (FTOZ) approaches. The anatomical landmarks and the content of this venous space were described and compared from these surgical perspectives. Results: The oculomotor triangle can be clearly exposed only by the FTOZ approach. Unlike EEEA, for the exposure of the clinoid triangle content, the anterior clinoid process removal is required for FTOZ and SETOA. The supra- and infratrochlear as well as the anteromedial and anterolateral triangles can be exposed by all three corridors. The most recently introduced SETOA allowed for the exposure of the entire lateral wall of the CS without entering its neurovascular structures and part of the posterior wall; furthermore, thanks to its anteroposterior trajectory, it allowed for the disclosure of the posterior ascending segment of the cavernous ICA with the related sympathetic plexus through the Mullan's triangle, in a minimally invasive fashion. Through the anterolateral triangle, the transorbital corridor allowed us to expose the lateral 180 degrees of the Vidian nerve and artery in the homonymous canal, the anterolateral aspect of the lacerum segment of the ICA at the transition zone from the petrous horizontal to the ascending posterior cavernous segment, surrounded by the carotid sympathetic plexus, and the medial Meckel's cave. Conclusions: Different regions of the cavernous sinus are better exposed by different surgical corridors. The relationship of the tumor with cranial nerves in the lateral wall guides the selection of the approach to cavernous sinus lesions. The transorbital endoscopic approach can be considered to be a safe and minimally invasive complementary surgical corridor to the well-established transcranial and endoscopic endonasal routes for the exposure of selected lesions of the cavernous sinus. Nevertheless, peer knowledge of the anatomy and a surgical learning curve are required.
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Affiliation(s)
- Sergio Corvino
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università di Napoli “Federico II”, 80131 Naples, Italy; (S.C.); (L.M.C.)
- PhD Program in Neuroscience, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università di Napoli “Federico II”, 80131 Naples, Italy
| | - Pedro L. Villanueva-Solórzano
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery “Manuel Velasco Suarez”, Mexico City 14269, Mexico;
| | - Martina Offi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy;
- Division of Neurosurgery, Catholic University of Rome, 00153 Rome, Italy
| | - Daniele Armocida
- Neurosurgery Division, Human Neurosciences Department, “Sapienza” University, 00185 Rome, Italy;
| | - Motonobu Nonaka
- Department of Neurosurgery, Kochi University Hospital, 185-1, Oko-cho, Kohasu, Kochi 783-8505, Japan;
| | - Giorgio Iaconetta
- Neurosurgical Clinic A.O.U. “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy;
| | - Felice Esposito
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università di Napoli “Federico II”, 80131 Naples, Italy; (S.C.); (L.M.C.)
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università di Napoli “Federico II”, 80131 Naples, Italy; (S.C.); (L.M.C.)
| | - Matteo de Notaris
- Neurosurgery Operative Unit, Department of Neuroscience, Coordinator Neuroanatomy Section Italian Society of Neurosurgery, G. Rummo Hospital, 82100 Benevento, Italy;
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13
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Di Somma A, De Rosa A, Ferrés A, Mosteiro A, Guizzardi G, Fassi JM, Topczewski TE, Reyes L, Roldán P, Torné R, Alobid I, Enseñat J. Endoscopic Transorbital Approach for the Management of Spheno-Orbital Meningiomas: Literature Review and Preliminary Experience. World Neurosurg 2023; 176:43-59. [PMID: 37024084 DOI: 10.1016/j.wneu.2023.03.126] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE The endoscopic transorbital approach (ETOA) is a minimally invasive approach that could be particularly appropriate for management of spheno-orbital meningiomas. The aim of this study was to perform a systematic review of the literature on the management of spheno-orbital meningiomas via the minimally invasive ETOA, searching for clinical scenarios in which this approach could be best indicated. A secondary aim was to describe 4 illustrative cases. METHODS A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data including patient demographics, tumor features, and surgical and postoperative outcomes were collected. Cases from our initial experience with ETOA were included in the data. RESULTS Data of 58 patients from 9 selected records and from our surgical series were collected. Subtotal, near-total, and gross total resection rates were 44.8%, 10.3%, and 32.7%, respectively. Symptom improvement after surgery was 100% for proptosis, 93% for visual impairment, and 87% for ophthalmoplegia. The most common postoperative complications were transient ophthalmoplegia and maxillary nerve hypoesthesia. Cerebrospinal fluid leak was reported in 2 patients. CONCLUSIONS Our findings support the use of the ETOA for management of spheno-orbital meningiomas, particularly in at least 3 clinical scenarios: 1) when predominant hyperostotic bone is present; 2) when a globular tumor not showing excessive medial or inferior infiltration is being treated; 3) as part of a multistage treatment for diffuse lesions.
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Affiliation(s)
- Alberto Di Somma
- Institut Clínic de Neurociències, Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Andrea De Rosa
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli "Federico II", Naples, Italy.
| | - Abel Ferrés
- Institut Clínic de Neurociències, Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Alejandra Mosteiro
- Institut Clínic de Neurociències, Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Giulia Guizzardi
- Institut Clínic de Neurociències, Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Jessica Matas Fassi
- Department of Ophthalmology, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Thomaz E Topczewski
- Institut Clínic de Neurociències, Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Luis Reyes
- Institut Clínic de Neurociències, Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Pedro Roldán
- Institut Clínic de Neurociències, Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Ramon Torné
- Institut Clínic de Neurociències, Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - Isam Alobid
- Skull Base Unit, ENT Department, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Universidad de Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Institut Clínic de Neurociències, Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
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14
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Corvino S, Guizzardi G, Sacco M, Corrivetti F, Bove I, Enseñat J, Colamaria A, Prats-Galino A, Solari D, Cavallo LM, Di Somma A, de Notaris M. The feasibility of three port endonasal, transorbital, and sublabial approach to the petroclival region: neurosurgical audit and multiportal anatomic quantitative investigation. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05498-6. [PMID: 36752892 DOI: 10.1007/s00701-023-05498-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/02/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE The petroclival region represents the "Achille's heel" for the neurosurgeons. Many ventral endoscopic routes to this region, mainly performed as isolated, have been described. The aim of the present study is to verify the feasibility of a modular, combined, multiportal approach to the petroclival region to overcome the limits of a single approach, in terms of exposure and working areas, brain retraction and manipulation of neurovascular structures. METHODS Four cadaver heads (8 sides) underwent endoscopic endonasal transclival, transorbital superior eyelid and contralateral sublabial transmaxillary-Caldwell-Luc approaches, to the petroclival region. CT scans were obtained before and after each approach to rigorously separate the contribution of each osteotomy and subsequentially to build a comprehensive 3D model of the progressively enlarged working area after each step. RESULTS The addition of the contralateral transmaxillary and transorbital corridors to the extended endoscopic endonasal transclival in a combined multiportal approach provides complementary paramedian trajectories to overcome the natural barrier represented by the parasellar and paraclival segments of the internal carotid artery, resulting in significantly greater area of exposure than a pure endonasal midline route (8,77 cm2 and 11,14 cm2 vs 4,68 cm2 and 5,83cm2, extradural and intradural, respectively). CONCLUSION The use of different endoscopic "head-on" trajectories can be combined in a wider multiportal extended approach to improve the ventral route to the most inaccessible petroclival regions. Finally, by combining these approaches and reiterating the importance of multiportal strategy, we quantitatively demonstrate the possibility to reach "far away" paramedian petroclival targets while preserving the neurovascular structures.
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Affiliation(s)
- Sergio Corvino
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Giulia Guizzardi
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Matteo Sacco
- Department of Neurosurgery, "Riuniti" Hospital, Foggia, Italy
| | - Francesco Corrivetti
- Department of Neurosurgery, San Luca Hospital, Vallo Della Lucania, Salerno, Italy.,Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy
| | - Ilaria Bove
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Joaquim Enseñat
- Departments of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Alberto Di Somma
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain. .,Departments of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain.
| | - Matteo de Notaris
- Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy.,Neurosurgery Operative Unit, Department of Neuroscience, "San Pio" Hospital, Benevento, Italy
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