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Loymak T, Tungsanga S, Abramov I, Sarris CE, Little AS, Preul MC. Comparison of Anatomic Exposure After Petrosectomy Using Anterior Transpetrosal and Endoscopic Endonasal Approaches: Experimental Cadaveric Study. World Neurosurg 2022; 161:e642-e653. [PMID: 35217231 DOI: 10.1016/j.wneu.2022.02.076] [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: 11/12/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Transcranial anterior petrosectomy (AP) is a classic approach; however, it is associated with adverse consequences. The endoscopic endonasal approach (EEA) has been developed as an alternative. We describe surgical techniques for AP and EEA and compare the anatomic exposures of each. METHODS Ten cadaveric heads (20 sides) were dissected. Specimens were divided into 4 groups: 1) AP, 2) EEA for medial petrosectomy (MP), 3) EEA for inferior petrosectomy (IP), and 4) EEA for inferomedial petrosectomy (IMP). Outcomes were areas of exposure, angles of attack to neurovascular structures, and bone resection volumes. RESULTS AP had a greater area of exposure than did MP and IP (P = 0.30, P < 0.01) and had a higher angle of attack to the distal part of the facial nerve-vestibulocochlear nerve (cranial nerve [CN] VII/VIII) complex than did IP and IMP (P < 0.01). MP had a lower angle of attack than IMP to the midpons (P = 0.04) and to the anterior inferior cerebellar artery (P < 0.01). Compared with IMP, IP had a lower angle of attack to the proximal part of the CN VII/VIII complex (P < 0.01) and the flocculus (P < 0.01). The bone resection volume in AP was significantly less than that in MP, IP, and IMP (P < 0.01). CONCLUSIONS AP and all EEA techniques had specific advantages for each specific area. We suggest AP for the ventrolateral pons and the anterior superior internal auditory canal, MP for the midline clivus, IP for the ventrolateral brainstem, and IMP to enhance the lateral corridor of the abducens nerve.
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Affiliation(s)
- Thanapong Loymak
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Somkanya Tungsanga
- Division of Nephrology, Department of Internal Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Irakliy Abramov
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Christina E Sarris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
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Loymak T, Belykh E, Abramov I, Tungsanga S, Sarris CE, Little AS, Preul MC. Comparative Analysis of Surgical Exposure among Endoscopic Endonasal Approaches to Petrosectomy: An Experimental Study in Cadavers. J Neurol Surg B Skull Base 2022; 83:526-535. [PMID: 36097500 PMCID: PMC9462962 DOI: 10.1055/s-0041-1741067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 11/12/2021] [Indexed: 01/16/2023] Open
Abstract
Objectives Endoscopic endonasal approaches (EEAs) for petrosectomies are evolving to reduce perioperative brain injuries and complications. Surgical terminology, techniques, landmarks, advantages, and limitations of these approaches remain ill defined. We quantitatively analyzed the anatomical relationships and differences between EEA exposures for medial, inferior, and inferomedial petrosectomies. Design This study presents anatomical dissection and quantitative analysis. Setting Cadaveric heads were used for dissection. EEAs were performed using the medial petrosectomy (MP), the inferior petrosectomy (IP), and the inferomedial petrosectomy (IMP) techniques. Participants Six cadaver heads (12 sides, total) were dissected; each technique was performed on four sides. Main Outcomes and Measures Outcomes included the area of exposure, visible distances, angles of attack, and bone resection volume. Results The IMP technique provided a greater area of exposure ( p < 0.01) and bone resection volume ( p < 0.01) when compared with the MP and IP techniques. The IMP technique had a longer working length of the abducens nerve (cranial nerve [CN] VI) than the MP technique ( p < 0.01). The IMP technique demonstrated higher angles of attack to specific neurovascular structures when compared with the MP (midpons [ p = 0.04], anterior inferior cerebellar artery [ p < 0.01], proximal part of the cisternal CN VI segment [ p = 0.02]) and IP (flocculus [ p = 0.02] and the proximal [ p = 0.02] and distal parts [ p = 0.02] of the CN VII/VIII complex) techniques. Conclusion Each of these approaches offers varying degrees of access to the petroclival region, and the surgical approach should be appropriately tailored to the pathology. Overall, the IMP technique provides greater EEA surgical exposure to vital neurovascular structures than the MP and the IP techniques.
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Affiliation(s)
- Thanapong Loymak
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Irakliy Abramov
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Somkanya Tungsanga
- Division of Nephrology, Department of Internal Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Christina E. Sarris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Andrew S. Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark C. Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona,Address for correspondence Mark C. Preul, MD c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center350 West Thomas Road, Phoenix, Arizona 85013
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Skandalakis GP, Komaitis S, Kalyvas A, Lani E, Kontrafouri C, Drosos E, Liakos F, Piagkou M, Placantonakis DG, Golfinos JG, Fountas KN, Kapsalaki EZ, Hadjipanayis CG, Stranjalis G, Koutsarnakis C. Dissecting the default mode network: direct structural evidence on the morphology and axonal connectivity of the fifth component of the cingulum bundle. J Neurosurg 2021; 134:1334-1345. [PMID: 32330886 DOI: 10.3171/2020.2.jns193177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 02/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although a growing body of data support the functional connectivity between the precuneus and the medial temporal lobe during states of resting consciousness as well as during a diverse array of higher-order functions, direct structural evidence on this subcortical circuitry is scarce. Here, the authors investigate the very existence, anatomical consistency, morphology, and spatial relationships of the cingulum bundle V (CB-V), a fiber tract that has been reported to reside close to the inferior arm of the cingulum (CingI). METHODS Fifteen normal, formalin-fixed cerebral hemispheres from adults were treated with Klingler's method and subsequently investigated through the fiber microdissection technique in a medial to lateral direction. RESULTS A distinct group of fibers is invariably identified in the subcortical territory of the posteromedial cortex, connecting the precuneus and the medial temporal lobe. This tract follows the trajectory of the parietooccipital sulcus in a close spatial relationship with the CingI and the sledge runner fasciculus. It extends inferiorly to the parahippocampal place area and retrosplenial complex area, followed by a lateral curve to terminate toward the fusiform face area (Brodmann area [BA] 37) and lateral piriform area (BA35). Taking into account the aforementioned subcortical architecture, the CB-V allegedly participates as a major subcortical stream within the default mode network, possibly subserving the transfer of multimodal cues relevant to visuospatial, facial, and mnemonic information to the precuneal hub. Although robust clinical evidence on the functional role of this stream is lacking, the modern neurosurgeon should be aware of this tract when manipulating cerebral areas en route to lesions residing in or around the ventricular trigone. CONCLUSIONS Through the fiber microdissection technique, the authors were able to provide original, direct structural evidence on the existence, morphology, axonal connectivity, and correlative anatomy of what proved to be a discrete white matter pathway, previously described as the CB-V, connecting the precuneus and medial temporal lobe.
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Affiliation(s)
- Georgios P Skandalakis
- 1Athens Microneurosurgery Laboratory, Evangelismos Hospital, Athens
- 2Department of Neurosurgery, National and Kapodistrian University of Athens
- 3Department of Anatomy, Medical School, National and Kapodistrian University of Athens
- 10Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Spyridon Komaitis
- 1Athens Microneurosurgery Laboratory, Evangelismos Hospital, Athens
- 2Department of Neurosurgery, National and Kapodistrian University of Athens
- 4Hellenic Center for Neurosurgical Research, "Petros Kokkalis," Athens, Greece
| | - Aristotelis Kalyvas
- 1Athens Microneurosurgery Laboratory, Evangelismos Hospital, Athens
- 2Department of Neurosurgery, National and Kapodistrian University of Athens
- 3Department of Anatomy, Medical School, National and Kapodistrian University of Athens
- 5Department of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Evgenia Lani
- 1Athens Microneurosurgery Laboratory, Evangelismos Hospital, Athens
- 2Department of Neurosurgery, National and Kapodistrian University of Athens
- 3Department of Anatomy, Medical School, National and Kapodistrian University of Athens
| | - Chrysoula Kontrafouri
- 1Athens Microneurosurgery Laboratory, Evangelismos Hospital, Athens
- 2Department of Neurosurgery, National and Kapodistrian University of Athens
- 3Department of Anatomy, Medical School, National and Kapodistrian University of Athens
| | - Evangelos Drosos
- 1Athens Microneurosurgery Laboratory, Evangelismos Hospital, Athens
- 2Department of Neurosurgery, National and Kapodistrian University of Athens
| | - Faidon Liakos
- 1Athens Microneurosurgery Laboratory, Evangelismos Hospital, Athens
- 3Department of Anatomy, Medical School, National and Kapodistrian University of Athens
| | - Maria Piagkou
- 1Athens Microneurosurgery Laboratory, Evangelismos Hospital, Athens
- 3Department of Anatomy, Medical School, National and Kapodistrian University of Athens
| | | | - John G Golfinos
- 6Department of Neurosurgery, NYU School of Medicine, New York, New York
| | - Kostas N Fountas
- 8Neurosurgery, School of Medicine, University of Thessaly, Larisa, Greece
| | | | - Constantinos G Hadjipanayis
- 9Department of Neurosurgery, Mount Sinai Union Square, New York; and
- 10Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - George Stranjalis
- 1Athens Microneurosurgery Laboratory, Evangelismos Hospital, Athens
- 2Department of Neurosurgery, National and Kapodistrian University of Athens
- 4Hellenic Center for Neurosurgical Research, "Petros Kokkalis," Athens, Greece
| | - Christos Koutsarnakis
- 1Athens Microneurosurgery Laboratory, Evangelismos Hospital, Athens
- 2Department of Neurosurgery, National and Kapodistrian University of Athens
- 3Department of Anatomy, Medical School, National and Kapodistrian University of Athens
- 4Hellenic Center for Neurosurgical Research, "Petros Kokkalis," Athens, Greece
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