1
|
Revuelta Barbero JM, Porto E, Prevedello DM, Noiphithak R, Yanez-Siller JC, Martinez-Perez R, Pradilla G. Quantitative Comparative Analysis of the Endoscope-Assisted Expanded Retrosigmoid Approach and the Far-Lateral Approach to the Inframeatal Area: An Anatomic Study With Surgical Implications. Oper Neurosurg (Hagerstown) 2023; 24:e187-e200. [PMID: 36701685 DOI: 10.1227/ons.0000000000000506] [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: 07/07/2022] [Accepted: 09/07/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The inframeatal area (IFMA) is a complex anatomic region of the posterior cranial fossa. Given its deep-seated location, tumors involving the IFMA represent a surgical challenge. OBJECTIVE To objectively compare the endoscope-assisted expanded retrosigmoid approach (ERSA) and the far-lateral supracondylar transtubercular approach (FLTA) to address the IFMA. METHODS Anatomic dissections were performed on 5 cadaveric heads (10 sides). The ERSAs were performed before and after the FLTAs. The surgical exposure, surgical freedom, and angles of attack to the IFMA were measured and compared for each approach. In addition, 2 illustrative clinical cases are reported. RESULTS Compared with FLTA, ERSA yielded a nonsignificantly smaller mean area of exposure, whereas FLTA provided a significantly larger mean area of surgical freedom, compared with ERSA ( P = .002). The mean horizontal and vertical angles of attack were significantly different between the approaches. In the vertical plane, FLTA yielded the broadest angle of attack at the root entry zone of the lower cranial nerves (CN; P < .004), whereas ERSA did so at the dural entry zone of CN VII/VIII ( P = .006). In the horizontal plane, FLTA achieved its broadest angle of attack at the root entry zone of the lower CNs ( P = 1.83) while ERSA at the dural entry zone of CN VII/VIII ( P = .37). CONCLUSION ERSA and FLTA granted a comparable exposure with the IFMA. Although FLTA may afford a larger area of surgical freedom, ERSA may be a suitable alternative to approach the IFMA, particularly to reach the most medial and superior aspects of this region. Conversely, FLTA may facilitate access to more caudally targets.
Collapse
Affiliation(s)
- J Manuel Revuelta Barbero
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
- Department of Neurosurgery, Medical College of Georgia, Augusta, Georgia, USA
| | - Edoardo Porto
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Raywat Noiphithak
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Juan C Yanez-Siller
- Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Rafael Martinez-Perez
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
2
|
Donofrio CA, Badaloni F, Riccio L, Morandini A, Bertuccio A, Generali D, Calbucci F, Servadei F, Fioravanti A. Posterior Petrous Meningiomas: Surgical Classification and Postoperative Outcomes in a Case Series of 130 Patients Operated via the Retrosigmoid Approach. World Neurosurg 2023; 171:e301-e308. [PMID: 36509329 DOI: 10.1016/j.wneu.2022.12.022] [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: 11/24/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE A standardized definition and classification of primary posterior petrous meningiomas (PPMs) is lacking, with consequent challenges in comparing different case series. This study aimed to provide an anatomical description and classification of PPMs analyzing a homogeneous series of patients operated via the retrosigmoid approach. METHODS PPMs originate laterally to the petro-occipital fissure within the venous ring composed of the superior petrosal, sigmoid, inferior petrosal, and cavernous sinuses. We proposed a classification based on tumor site of origin, direction of growth relative to the internal acoustic meatus, and cranial nerves' displacement. Four types of PPMs were defined: retromeatal (type A), meatal (type B), premeatal (type C), and broad-based (type D). We performed a retrospective analysis of 130 consecutive patients with PPMs who underwent surgery as first-line treatment. RESULTS The PPM classification predicted clinical presentation, postoperative morbidity, and resection rates. Headache, hydrocephalus, and cerebellar deficits were more common in type A (59.0%, 37.7%, 49.2%) and type D (66.7%, 66.7%, 33.3%). Hypoacusia/anacusia was more common in type B (87.5%), while trigeminal hypoesthesia/anesthesia was more common in type C (85.0%). After surgery, patients with type A and D PPMs were at higher risk to develop cerebellar deficits (11.5%-22.2%), whereas patients with type B and C PPMs presented with hypoacusia/anacusia (12.5%) and trigeminal deficits (10.0%), respectively. The near-total resection rate was higher in type A (91.8%), followed by types B (82.5%), C (80.0%), and D (77.8%) PPMs. CONCLUSIONS The PPM surgical classification has an operative and prognostic relevance. In expert hands, the retrosigmoid approach represents a safe and effective approach to remove PPMs.
Collapse
Affiliation(s)
- Carmine Antonio Donofrio
- Department of Neurosurgery, ASST Cremona, Cremona, Italy; Division of Biology and Genetics, Department of Molecular and Translational Medicine, Faculty of Medicine, University of Brescia, Brescia, Italy.
| | - Filippo Badaloni
- Department of Neurosurgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Lucia Riccio
- Department of Neurosurgery, ASST Cremona, Cremona, Italy
| | | | - Alessandro Bertuccio
- Department of Neurosurgery, Santi Antonio e Biagio e Cesare Arrigo Alessandria Hospital, Alessandria, Italy
| | - Daniele Generali
- Medical Oncology and Translational Research Unit, ASST Cremona, Cremona, Italy; Department of Medicine, Surgery and Health Sciences, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Fabio Calbucci
- Department of Neurosurgery, Maria Cecilia Hospital, Cotignola, Italy
| | - Franco Servadei
- Humanitas Clinical and Research Center-IRCCS, Humanitas University, Rozzano, Milano, Italy
| | | |
Collapse
|
3
|
Sykopetrites V, Taibah A, Piras G, Giannuzzi AL, Mancini F, Sanna M. The otologic approach in the management of posterior petrous surface meningiomas. Eur Arch Otorhinolaryngol 2022; 279:5655-5665. [PMID: 35767053 DOI: 10.1007/s00405-022-07442-3] [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: 02/13/2022] [Accepted: 05/09/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE Report our experience in the management of posterior petrous surface meningiomas (PPSMs), and identify features that affect hearing, facial nerve (FN) function, and control of the disease. METHODS Retrospective case series of 131 patients surgically managed for PPSMs. FN status, hearing and tumour radicality were assessed and compared between patients with tumours of different locations (Desgeorges classification) and internal auditory canal involvement (IAC). RESULTS At the time of surgery 74.8% of patients had a hearing loss. Hearing was mostly unserviceable in tumors attached to the meatus. Pure tone audiometry did not correlate to IAC extension, while speech discrimination scores were statistically worse when the tumor occupied the IAC (unpaired t test, p = 0.0152). Similarly, extrameatal tumors undergoing removal by otic preserving techniques maintained postoperative hearing, whereas hearing worsened significantly in tumors involving the IAC (paired t test, p = 0.048). The FN was affected preoperatively in 11.4% of cases. Postoperative FN palsy was significantly correlated to the IAC involvement (Fisher's exact test, p = 0.0013), while it was not correlated to tumor size. According to the Desgeorges classification, a postoperative FN palsy complicated the majority of anteriorly extending tumors and, two-fifths of meatus centred tumors. 75% of posterior located tumors had a postoperative FN grade I HB. CONCLUSIONS Since the involvement of the IAC by the tumor affects both hearing and FN function, the IAC is of primary importance in PPSMs and should be studied and addressed as much as the tumor location in the CPA.
Collapse
Affiliation(s)
- Vittoria Sykopetrites
- Department of Otology and Skull Base Surgery, Gruppo Otologico and Mario Sanna Foundation, Piacenza, Rome, Italy. .,Casa di Cura "Piacenza" S.P.A., Via Emmanueli 42, 29121, Piacenza, Italy.
| | - Abdelkader Taibah
- Department of Otology and Skull Base Surgery, Gruppo Otologico and Mario Sanna Foundation, Piacenza, Rome, Italy.,Casa di Cura "Piacenza" S.P.A., Via Emmanueli 42, 29121, Piacenza, Italy
| | - Gianluca Piras
- Department of Otology and Skull Base Surgery, Gruppo Otologico and Mario Sanna Foundation, Piacenza, Rome, Italy.,Casa di Cura "Piacenza" S.P.A., Via Emmanueli 42, 29121, Piacenza, Italy
| | - Anna Lisa Giannuzzi
- Department of Otology and Skull Base Surgery, Gruppo Otologico and Mario Sanna Foundation, Piacenza, Rome, Italy.,Casa di Cura "Piacenza" S.P.A., Via Emmanueli 42, 29121, Piacenza, Italy
| | - Fernando Mancini
- Department of Otology and Skull Base Surgery, Gruppo Otologico and Mario Sanna Foundation, Piacenza, Rome, Italy.,Casa di Cura "Piacenza" S.P.A., Via Emmanueli 42, 29121, Piacenza, Italy
| | - Mario Sanna
- Department of Otology and Skull Base Surgery, Gruppo Otologico and Mario Sanna Foundation, Piacenza, Rome, Italy.,Casa di Cura "Piacenza" S.P.A., Via Emmanueli 42, 29121, Piacenza, Italy
| |
Collapse
|
4
|
Predictors of hearing functional outcome following surgery for cerebellopontine angle meningioma. J Neurooncol 2022; 157:165-176. [PMID: 35113287 DOI: 10.1007/s11060-022-03958-0] [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: 11/19/2021] [Accepted: 01/28/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Cerebellopontine angle (CPA) meningiomas can affect hearing function and require expeditious treatment to prevent permanent hearing loss. The authors sought to determine the factors associated with functional hearing outcome in CPA meningioma patients treated with surgery and/or radiation therapy in the form of either stereotactic radiosurgery or stereotactic radiation therapy. METHODS Consecutive patients with CPA meningiomas who had presented at our hospital from 2008 to 2018 were identified through retrospective chart review. Hearing function (as defined by pure tone average (PTA) and speech discrimination score (SDS) on Audiogram) was assessed before and after surgery for CPA meningioma. Audiograms with PTA > 50 dB and SDS < 69% were defined as poor hearing functional outcome. Multivariable Cox Proportional Hazards Regression Model was used to assess the associations between pre-operative hearing functional assessment and post-operative hearing functional outcomes. RESULTS The study cohort included 31 patients (80.6% females, with a mean age of 61.3 ± 15.2 years) with a median clinical follow-up of 5 months (range: 1 week-98 months). The mean pre-operative PTA and SDS were 23.8 ± 11.2 dB and 64.4 ± 22.2% respectively. At the last visit, there was significant hearing recovery, with an improvement of 29.7 ± 18.0 dB (p < 0.001) and 87.6 ± 17.8% (p < 0.001) in PTA and SDS respectively. After adjusting for age, gender, tumor volume, location, and tumor classification, Multivariable Cox Proportional Hazards Regression Model was conducted which revealed that patients undergoing surgery through retro sigmoid approach [Hazards Ratio (HR): 32.1, 95% Confidence Interval (CI): 2.11-491.0, p = 0.01] and gross total resection (GTR) (HR: 2.99, 95% CI: 1.09-9.32, p = 0.05) had significantly higher risk of poor hearing functional outcome compared to petrosal approach and near/subtotal resection. Moreover, patients with poor preoperative hearing had 85% higher chance of poor hearing functional outcome postoperatively (HR: 0.15, 95%CI: 0.03-0.59, p = 0.007). CONCLUSION Postoperative improvement in hearing is a reasonable expectation following surgery for CPA meningioma. Preoperative hearing, surgical approach and extent of surgical resection are predictive factors of postoperative hearing function outcome and can therefore aid in identification of patients at higher risk of hearing loss.
Collapse
|
5
|
Abstract
Cerebellopontine angle (CPA) meningiomas arise from the petrous face of the temporal bone, which forms the lateral boundary of the CPA. They can be categorized into anterior, middle, and posterior, based on their attachment in relation to the internal acoustic meatus. Each of them presents with their own characteristic clinical syndromes. Because of their close proximity to neurovascular structures, they pose a challenge during surgery. Microsurgery remains the primary treatment modality for large and symptomatic meningiomas. The retrosigmoid approach provides an ideal access for most of the tumors in this location. Radiosurgery is the primary modality of adjuvant therapy for residual, recurrent, and small lesions. Fully fractionated external beam radiotherapy can be used for larger, broader-based residual/recurrent tumors. Management of these complex lesions should include patient preferences and a team approach, including a skull base neurosurgeon, neurotologist, and radiation oncologist.
Collapse
Affiliation(s)
- Muhammad Salman Ali
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States
| | - Stephen T Magill
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
| | - Michael W McDermott
- Miami Neuroscience Institute, Baptist Health of South Florida, Miami, FL, United States; Division of Neuroscience, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, United States
| |
Collapse
|
6
|
Tomasello F, Angileri FF, Conti A, Scibilia A, Cardali S, La Torre D, Germanò A. Petrosal Meningiomas: Factors Affecting Outcome and the Role of Intraoperative Multimodal Assistance to Microsurgery. Neurosurgery 2018; 84:1313-1324. [DOI: 10.1093/neuros/nyy188] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 04/19/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Alfredo Conti
- Department of Neurosurgery, University of Messina, Messina, Italy
- Depart-ment of Neurosurgery, Charité Univer-sitätsmedizin, Berlin, Germany
| | | | | | | | - Antonino Germanò
- Department of Neurosurgery, University of Messina, Messina, Italy
| |
Collapse
|
7
|
GOTO T, OHATA K. Surgical Resectability of Skull Base Meningiomas. Neurol Med Chir (Tokyo) 2016; 56:372-8. [PMID: 27076382 PMCID: PMC4945595 DOI: 10.2176/nmc.ra.2015-0354] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 03/11/2016] [Indexed: 12/11/2022] Open
Abstract
With recent advances in surgical technology such as preoperative imaging, neuro-monitoring, and surgical instruments, the surgical resectability of intracranial meningiomas has increased over the last two decades. This study reviewed clinical articles regarding the surgical treatment of meningiomas to clarify the role of surgical excision, with a focus on skull base meningiomas. We sub-classified clinical articles about skull base meningiomas into two categories (anterior and middle fossa meningiomas; and posterior fossa meningiomas) and reviewed papers in each category. In cases with anterior and middle fossa meningiomas, surgical resectability has reached a sufficient level to maximize functional preservation. In cases of posterior fossa meningioma, however, surgical respectability remains insufficient even with full use of recent surgical modalities. Continuous refining of operative procedures is required to obtain more satisfactory outcomes, especially for posterior fossa meningioma. In addition, recent long-term outcomes of stereotactic radiosurgery (SRS) were acceptable for controlling the skull base meningiomas. Therefore, combination with surgical excision and SRS should be considered in complicated skull base meningiomas.
Collapse
Affiliation(s)
- Takeo GOTO
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka
| | - Kenji OHATA
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Abeno-ku, Osaka
| |
Collapse
|
8
|
Differences in clinical presentation, intraoperative findings and outcome between petroclival and lateral posterior pyramid meningioma. Clin Neurol Neurosurg 2016; 141:122-8. [PMID: 26826961 DOI: 10.1016/j.clineuro.2016.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 12/29/2015] [Accepted: 01/05/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The goal of this study was to determine the impact of the location of the most frequent skull base meningioma of the posterior fossa, i.e. petroclival (PCM) and lateral posterior pyramid meningioma (LPPM) on clinical presentation, surgical treatment and treatment results. PATIENTS AND METHODS We retrospectively reviewed a consecutive series of patients operated on for PCM (n=46) and LPPM (n=32). Uni- and multivariate analyses were performed to identify differences in clinical presentation, surgical treatment and pre-, intra- and postoperative factors of influence upon the outcome parameters: Complications rate, mortality, tumour recurrence/progress, hospital stay, Karnofsky Performance Score (KPS). RESULTS At Presentation, the rate of dizziness was higher in LPPM (56% vs. 7%, p<0,001) and trigeminal nerve impairment was more frequent in PCM (50% vs. 3%, p<0,001). Complete tumour resections were more often achieved (91% vs. 39%, p<0,001), and surgery lasted shorter (median: 247 min vs. 500 min, p<0,001) with less blood loss (median: 525 ml vs. 1000 ml, p<0,001) in LPPM compared to PCM. The overall complication rates (73% vs. 31%, p<0,001) as well the rate of irreversible complications (57% vs. 9%, p<0,004) were higher in PCM than in LPPM. The most frequent complications of PCM surgery were eye movement (46% vs. 6%, p<0,001), facial nerve (28% vs. 3%, p<0.02) and swallowing impairments (21% vs. 3%, p<0.02). The perioperative mortality was 11% in PCM and 0% in LPPM patients. In the multivariate analyses, KPS at discharge correlate positively with age (p=0.034) and preoperative KPS (p=0.0048) in LPPM and positively with staged resection (p=0.056) and negatively with the occurrence of surgical complications (p=0,0427) in PCM. Hospitalization time correlated with the blood loss (p<0,001) for PCM, negatively with the preoperative KPS (p=0.0002) for PCM and LPPM and positively with tumour diameter (p=0.0001) and non-surgical complications rate (p=0.0001) for LPPM. CONCLUSION As compared to LPPM, surgical treatment of PCM is associated with higher morbidity and mortality. The outcome of LPPM was primarily influenced by preoperative factors: Patients age, tumour size, preoperative KPS. The outcome of PCM was primarily influenced by intraoperative factors like: blood loss, surgery duration, staged tumour resection and the surgical complications rate.
Collapse
|
9
|
Miller ME, Mastrodimos B, Cueva RA. Facial nerve function after the extended translabyrinthine approach. J Neurol Surg B Skull Base 2015; 76:1-6. [PMID: 25685642 DOI: 10.1055/s-0034-1368146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 11/23/2013] [Indexed: 10/24/2022] Open
Abstract
Objective To evaluate facial nerve function after excision of petroclival/anterior cerebellopontine angle (CPA) meningiomas by the extended translabyrinthine (EXTL) approach and compare these with outcomes after the transcochlear and transotic approaches. Design Retrospective chart review. Setting/Participants A search of archived surgical cases at a single institution between January 1, 1995, and January 1, 2012. Main Outcome Measures Facial function measured on the House-Brackmann (HB) scale. Results A total of 16 patients underwent the EXTL approach for primary excision of petroclival meningiomas. Average tumor size was 4.6 cm, and six patients had gross total resection. Average length of follow-up was 36.4 months. Two patients required reoperation for tumor regrowth. Preoperative facial function was HB I or II in all patients with available examinations. Immediate postoperative facial nerve function ranged from HB I to HB VI. In patients with an intact facial nerve at surgery, all but one had long-term facial function of HB I or II. A robust response on intraoperative facial nerve monitoring was prognostic of favorable long-term facial function. Facial function declined in some patients after postoperative radiation or revision surgery. Conclusions The EXTL approach allows excellent exposure of petroclival/anterior CPA lesions and should be favored to improve facial outcomes.
Collapse
Affiliation(s)
- Mia E Miller
- Department of Otolaryngology, University of California at San Francisco, San Francisco, California, United States
| | - Bill Mastrodimos
- Department of Neurosurgery, Kaiser Permanente San Diego, San Diego, California, United States
| | - Roberto A Cueva
- Department of Otolaryngology, Kaiser Permanente San Diego, San Diego, California, United States
| |
Collapse
|
10
|
Peyre M, Bozorg-Grayeli A, Rey A, Sterkers O, Kalamarides M. Posterior petrous bone meningiomas: surgical experience in 53 patients and literature review. Neurosurg Rev 2011; 35:53-66; discussion 66. [DOI: 10.1007/s10143-011-0333-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 03/22/2011] [Accepted: 05/15/2011] [Indexed: 11/29/2022]
|
11
|
Roth J, Singh A, Nyquist G, Fraser JF, Bernardo A, Anand VK, Schwartz TH. Three-dimensional and 2-dimensional endoscopic exposure of midline cranial base targets using expanded endonasal and transcranial approaches. Neurosurgery 2010; 65:1116-28; discussion 1128-30. [PMID: 19934971 DOI: 10.1227/01.neu.0000360340.85186.7a] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Endoscopic endonasal approaches provide an access method to the midline cranial base. To integrate these approaches into neurosurgical practice, the extent of their anatomic exposure must be compared with that provided by more traditional transcranial approaches. METHODS Ten fresh cadaver heads were studied. Both endonasal and transcranial approaches to the midline cranial base were performed. The midline cranial base was divided into several areas, and the relative exposure provided by each approach was described and presented in both 2-dimensional and 3-dimensional images. Limitations and advantages of each approach are discussed. RESULTS The endonasal approaches achieved a direct and wide exposure of the midline extracranial and intracranial cranial base anatomy. The main lateral limitations of the endonasal approaches were the optic nerves, lateral cavernous sinus, vidian nerve, internal carotid artery, abducens nerve in Dorello's canal, jugular tubercle, and hypoglossal canals. Limitations of the transcranial approaches were the neurovascular structures which lie in the operative corridor and create narrow working spaces. CONCLUSION The endonasal approaches achieve a direct and wide exposure of the midline cranial base bilaterally. Lateral exposure, beyond the cranial nerves and carotid artery, are challenging. Transcranial approaches are limited by the narrow corridors provided by the cranial nerves, and they do not visualize the contralateral paramedian cranial base very well. Three-dimensional endoscopes augment the spatial orientation and may improve patient safety and the learning curve for endoscopic approaches to the midline cranial base.
Collapse
Affiliation(s)
- Jonathan Roth
- Department of Neurological Surgery, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York 10021, USA
| | | | | | | | | | | | | |
Collapse
|
12
|
|