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Carlstrom LP, Dornhoffer JR, Randall NR, Peris Celda M, Van Gompel JJ, Driscoll CL, Carlson ML, Link MJ. Anatomic Variants in the Anterior Inferior Cerebellar Artery Encountered During Resection of Vestibular Schwannomas. Oper Neurosurg (Hagerstown) 2023; 25:512-520. [PMID: 37729626 DOI: 10.1227/ons.0000000000000881] [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: 03/30/2023] [Accepted: 06/21/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Vestibular schwannomas (VS) are often phenotypically benign lesions that may be technically challenging to resect because of involvement of neurovascular structures. The anterior inferior cerebellar artery (AICA) is commonly identified near VS, with variable position in relation to the tumor; however, little published literature describes anatomic and pathologic variants of AICA observed during VS resection. METHODS A prospectively maintained cohort of surgically managed VS with available operative reports and clinical/radiographic follow-up was queried and reviewed for noted aberrations. RESULTS We identified 66 cases with noted AICA abnormalities among 880 reviewer cases, including 20 loops extending into the internal auditory canal (2.3%), 18 arteries embedded in dura (2.0%), 15 AICA branches directly within VS (1.7%), 8 main trunk arteries coursing between cranial nerves 7 and 8 (0.9%), 3 arteries embedded in temporal bone (0.2%), 1 aneurysm (0.1%), and 1 artery bifurcating cranial nerve 6 (0.1%). The median age of AICA-variant patients was 55 years (range 19-74), and 29 were female (45%). Compared with the other AICA variants, tumors embedded with AICA tended to be larger lesions on maximal axial diameter (2.9 vs 1.6 cm; P = .006), they more commonly underwent less than total resection (73% vs 28%; P = .0001), and they had higher rates postoperative House-Brackmann scores >2 (47% vs 20%; P = .005). Two patients had radiographic and symptomatic postoperative cerebral ischemia or hemorrhage-1 from a bone-encased AICA and 1 from a dural embedded variant. CONCLUSION Anatomic variants of AICA occur in approximately 7% of VS operations. Most aberrations do not affect surgical or clinical outcomes, and the rate of major vascular injury was low. However, certain types variably add operative time and in the case of AICA encasement in the tumor, likely indicate a more aggressive tumor phenotype with lower rates of gross total resection and high incidences of facial nerve weakness.
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Affiliation(s)
- Lucas P Carlstrom
- Department of Neurosurgery, Mayo Clinic, Rochester , Minnesota , USA
| | | | | | - Maria Peris Celda
- Department of Neurosurgery, Mayo Clinic, Rochester , Minnesota , USA
| | - Jamie J Van Gompel
- Department of Neurosurgery, Mayo Clinic, Rochester , Minnesota , USA
- Department of Otolaryngology, Mayo Clinic, Rochester , Minnesota , USA
| | - Colin L Driscoll
- Department of Neurosurgery, Mayo Clinic, Rochester , Minnesota , USA
- Department of Otolaryngology, Mayo Clinic, Rochester , Minnesota , USA
| | - Matthew L Carlson
- Department of Neurosurgery, Mayo Clinic, Rochester , Minnesota , USA
- Department of Otolaryngology, Mayo Clinic, Rochester , Minnesota , USA
| | - Michael J Link
- Department of Neurosurgery, Mayo Clinic, Rochester , Minnesota , USA
- Department of Otolaryngology, Mayo Clinic, Rochester , Minnesota , USA
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Roman A, Tufegdzic B, Pinto V, Lamperti M, Elhammady M, Roser F. After the Knife: A Detailed Roadmap for Vestibular Schwannoma Resection in the Semi-Sitting Position - How I do it. World Neurosurg 2023; 175:e1341-e1347. [PMID: 37169076 DOI: 10.1016/j.wneu.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/29/2023] [Accepted: 05/01/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Vestibular schwannoma surgery remains a neurosurgical challenge, with known risks, dependent on a number of factors, from patient selection to surgical experience of the team. The semi-sitting position has gained popularity as an alternative to the traditional supine position for vestibular schwannoma resection due to potential advantages such as improved surgical exposure due to clearer surgical field and anatomical orientation. However, there is a lack of standardized protocols for performing the procedure in the semi-sitting position, leading to variations in surgical techniques and outcomes. METHODS In this study, we aimed to establish a standardized approach for vestibular schwannoma resection using the semi-sitting position. Initiating after final position for semi-sitting, the authors have divided the surgical steps into five major parts for improved understanding and replication. Surgical techniques were analyzed through one hundred steps to identify commonalities, determining the optimal procedural steps for the semi-sitting position using surgical video for visual conceptualization. RESULTS The analysis described one hundred steps for vestibular schwannoma resection in the semi-sitting position, with visual demonstration of the various parts of the procedure through surgical videos. Specific recommendations for each step were outlined, including appropriate approach, monitoring strategies, and tumor and posterior fossa structures manipulation. Five major parts of the procedure were identified, leading to a reproducible standardization of the surgical procedure of vestibular schwannoma resection in the semi-sitting position. CONCLUSIONS This study provides a comprehensive standardized protocol for the semi-sitting procedure in vestibular schwannoma resection. By establishing a consistent approach, surgeons can minimize variations in surgical techniques and improve patient outcomes. The identified steps and recommendations can serve as a valuable resource for surgical teams involved in vestibular schwannoma resection and facilitate the dissemination and reproducibility of best practices.
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Affiliation(s)
- Alex Roman
- Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE.
| | - Boris Tufegdzic
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Vania Pinto
- Neurophysiology, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Massimo Lamperti
- Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | | | - Florian Roser
- Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
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Peto I, Noureldine MHA, Zavadskiy G, Pressman E, Flores-Milan G, van Loveren H, Agazzi S. Postoperative magnetic resonance imaging signal changes in middle cerebral peduncle after vestibular schwannoma surgery. Br J Neurosurg 2022; 36:712-719. [PMID: 35913025 DOI: 10.1080/02688697.2022.2102147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND PURPOSE Preoperative compression of middle cerebellar peduncle (MCP) is often observed in vestibular schwannomas. Its re-expansion is expected after tumour resection, however, frequently its thickness remains unchanged or undergoes further atrophy. Similarly, increased MCP FLAIR signal is often observed and thought to be associated with intraoperative MCP injury. This study investigates the dynamics of MCP FLAIR signal changes over time and their implications in long-term MCP atrophy. MATERIALS AND METHODS Retrospective analysis of patients operated between 2011 and 2019 was performed. Measurements of FLAIR signals and MCP thickness were performed preoperatively, postoperatively and at follow-up. RESULTS 28 patients (15 females, mean age 51.94 years) were included. The mean follow-up was 23.98 months. The mean tumour size was 2.99 cm. The MCP FLAIR signal was elevated preoperatively in 10 (35.7%) patients and further increased postoperatively in 22 (78.6%), followed by its decrease at follow up (7 patients, 25%). An immediate postoperative re-expansion of middle cerebellar peduncle was observed in 24 (85.7%) patients. No association between tumour size and preoperative FLAIR was established, however tumour size was negatively associated with the MCP thickness. A significant negative association between a postoperative FLAIR and follow-up thickness (p < 0.001) was noted, even if controlling for tumour size and both tumour size and preoperative MCP thickness. CONCLUSION In patients with vestibular schwannomas undergoing surgical resection, the middle cerebellar peduncle FLAIR signal seems to associated with long term thickness of MCP, regardless of its initial size, however does not seem to correlate with the clinical outcome.
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Affiliation(s)
- Ivo Peto
- Morsani College of Medicine, Department of Neurosurgery and Brain Repair, Tampa General Hospital, University of South Florida, Tampa, Florida, USA
| | - Mohammad Hassan A Noureldine
- University of South Florida Morsani College of Medicine, Department of General Surgery, Tampa General Hospital, Tampa, Florida, USA
| | - Gleb Zavadskiy
- Departmenf of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Elliot Pressman
- Morsani College of Medicine, Department of Neurosurgery and Brain Repair, Tampa General Hospital, University of South Florida, Tampa, Florida, USA
| | - Gabriel Flores-Milan
- Morsani College of Medicine, Department of Neurosurgery and Brain Repair, Tampa General Hospital, University of South Florida, Tampa, Florida, USA
| | - Harry van Loveren
- Morsani College of Medicine, Department of Neurosurgery and Brain Repair, Tampa General Hospital, University of South Florida, Tampa, Florida, USA
| | - Siviero Agazzi
- Morsani College of Medicine, Department of Neurosurgery and Brain Repair, Tampa General Hospital, University of South Florida, Tampa, Florida, USA
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Bocanegra-Becerra JE, Meyer J, Deep NL, Weisskopf PA, Bendok BR. Commentary: Intraoperative Management of Double Anterior Inferior Cerebellar Artery Vascular Loops Adherent to Dura During Vestibular Schwannoma Resection: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e373-e374. [DOI: 10.1227/ons.0000000000000434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/02/2022] [Indexed: 11/06/2022] Open
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Rayan T, Helal A, Graffeo CS, Perry A, Carlstrom LP, Driscoll CLW, Link MJ. Cerebrovascular Complications of Vestibular Schwannoma Surgery. Skull Base Surg 2022; 83:e443-e448. [DOI: 10.1055/s-0041-1730895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
Abstract
Objective Cerebrovascular complications (CVC) are rare consequences of vestibular schwannoma (VS) surgery. Our objective was to assess incidences of findings suggestive of postoperative CVC in a large single surgeon cohort, as well as potential risk factors, and implications.
Study Design A cohort of 591 patients was retrospectively reviewed. Postoperative magnetic resonance images were screened for findings suggestive of stroke, T2 hyperintensity in the cerebellopontine angle structures or new encephalomalacia. Clinical records were queried for findings consistent with postoperative CVC.
Results In total, 61 patients had radiographic findings consistent with possible postoperative CVC (10%); of them, eight had documented intraoperative vascular injury (1.4%), and four had postoperative clinical exam changes indicative of CVC (0.7%). Clinically manifest intraoperative vascular injuries occurred in four patients and involved the petrosal venous complex (n = 3, 5%) or anterior inferior cerebellar artery (n = 1, 2%); clinical deficits included hemiparesis (n = 1, 2%), facial anesthesia (n = 2, 4%), dysphagia (n = 2, 2%), and unfavorable facial nerve function in two (50%). Three out of four patients in this group required out-of-home placement (75%). Clinical CVCs (n = 4) were not significantly associated with tumor size, tumor cyst, gross total resection, or length of stay. Patients with clinical CVC were significantly more likely to require posthospitalization rehabilitation (19 vs. 75%, p = 0.02; 14 vs. 100%, p = 0.0002).
Conclusion Although radiographic findings suggestive of CVC were unexpectedly common in this cohort, intraoperative vascular injury and postoperative clinical CVC were exceedingly rare. The association between unfavorable facial nerve outcome and clinical CVC is likely a marker for more difficult operations, predisposing to higher risk of complications.
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Affiliation(s)
- Tarek Rayan
- Department of Neurosurgery, Alexandria University, Alexandria, Egypt
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Ahmed Helal
- Department of Neurosurgery, Alexandria University, Alexandria, Egypt
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Lucas P. Carlstrom
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Colin L. W. Driscoll
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Departments of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael J. Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Departments of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
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Maxwell AK, Muelleman T, Barnard Z, Slattery WH, Mehta GU, Lekovic GP. Clinical Significance of Middle Cerebellar Peduncle Ischemia After Translabyrinthine Vestibular Schwannoma Resection. Otol Neurotol 2021; 42:e930-e935. [PMID: 33900231 DOI: 10.1097/mao.0000000000003152] [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: 11/27/2022]
Abstract
OBJECTIVE To assess clinical symptoms, signs, and radiographic evolution of middle cerebellar peduncle (MCP) diffusion restriction (DR) abnormalities following vestibular schwannoma (VS) resection. STUDY DESIGN Retrospective chart and imaging review. SETTING Tertiary-referral neurotology and neurosurgery practice. PATIENTS All consecutive patients who underwent translabyrinthine VS resection over a 2-year period (August 2017-May 2019). INTERVENTION Translabyrinthine craniotomy for VS resection. MAIN OUTCOME MEASURES Magnetic resonance imaging (MRI) obtained on postoperative day 1 were reviewed for DR within the pons and cerebellum, with 3 months follow-up MRI to assess for evolution of these vascular changes. RESULTS Of the 31 patients who met inclusion criteria, MRI demonstrated MCP DR consistent with acute ischemia in 29% (9/31). Of those, two showed corresponding T2 signal abnormalities on follow up MRI consistent with cerebrovascular accident (CVA) within the MCP. Both had severe gait ataxia and dysmetria requiring acute rehabilitation admission and significantly larger tumors (p = 0.02). The remaining seven were asymptomatic, and DR abnormality resolved without lasting radiographic changes. Brainstem compression was present in 100% of patients with postoperative MCP DR (mean MCP ipsilateral:contralateral ratio 0.59 ± 0.19), and 68.1% of those without (mean MCP ratio 0.71 ± 0.25), a difference that was not statistically significant (p = 0.14). In the two patients with CVA, MCP asymmetry persisted, whereas the asymmetry resolved in all others. CONCLUSIONS Asymptomatic acute MCP ischemia discovered incidentally does not require intervention. However, when the ischemic area is large and patients are symptomatic, especially if an acute rehabilitation admission is required, surgeons should suspect true CVA.
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Surgeons' experience of venous risk with CPA surgery. Neurosurg Rev 2020; 44:1675-1685. [PMID: 32772296 DOI: 10.1007/s10143-020-01365-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/23/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Abstract
The study aims to systematize neurosurgeons' practical knowledge of venous sacrifice as applied to the posterior fossa region and to analyze the collected data to present and preserve relevant experience and expert knowledge for current and future practicing neurosurgeons. The venous structures assessed were the superior petrosal vein (SPV), sigmoid sinus (SS), and the tentorial veins (TV). The survey is constructed to obtain surgeons' idea of assessed risk when sacrificing specific venous structures during posterior fossa surgery. They were asked how they prep for surgery, number of operations conducted, and their basis of knowledge. Collected data were mainly qualitative and analyzed with a mixed-method approach. A mean absolute deviation was calculated measuring rate of disagreement for a given substructure. Consensus existed among the participating surgeons that sacrificing the SPV and the TV was considered safe. Although, the risk of death when occluding major structures like the main trunk of the SPV, one of the SS' and or a total occlusion of all TV yielded high risk of death. The risk of infarction was often too apparent to discredit even with low risk of death among an experienced class of surgeons. Our findings provide an overview of surgical risk associated with venous sacrifice. This will minimize cases where indispensable practical knowledge on safe handling veins in the cerebellopontine angle is either to be lost or taught among few when the neurosurgeons retire. This will lower the disagreement regarding risks and increase the quality of surgical decision-making.
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