1
|
Mosteiro A, Codes M, Tafuto R, Manfrellotti R, Torales J, Enseñat J, Di Somma A, Prats-Galino A. Transorbital approach to the cavernous sinus: an anatomical study of the related cranial nerves. Front Neuroanat 2024; 18:1367533. [PMID: 38693948 PMCID: PMC11061526 DOI: 10.3389/fnana.2024.1367533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/06/2024] [Indexed: 05/03/2024] Open
Abstract
Background The cavernous sinus (CS) is a demanding surgical territory, given its deep location and the involvement of multiple neurovascular structures. Subjected to recurrent discussion on the optimal surgical access, the endoscopic transorbital approach has been recently proposed as a feasible route for selected lesions in the lateral CS. Still, for this technique to safely evolve and consolidate, a comprehensive anatomical description of involved cranial nerves, dural ligaments, and arterial relations is needed. Objective Detailed anatomical description of the CS, the course of III, IV, VI, and V cranial nerves, and C3-C7 segments of the carotid artery, all described from the ventrolateral endoscopic transorbital perspective. Methods Five embalmed human cadaveric heads (10 sides) were dissected. An endoscopic transorbital approach with lateral orbital rim removal, anterior clinoidectomy, and petrosectomy was performed. The course of the upper cranial nerves was followed from their apparent origin in the brainstem, through the middle fossa or cavernous sinus, and up to their entrance to the orbit. Neuronavigation was used to follow the course of the nerves and to measure their length of surgical exposure. Results The transorbital approach allowed us to visualize the lateral wall of the CS, with cranial nerves III, IV, V1-3, and VI. Anterior clinoidectomy and opening of the frontal dura and the oculomotor triangle revealed the complete course of the III nerve, an average of 37 (±2) mm in length. Opening the trigeminal pore and cutting the tentorium permitted to follow the IV nerve from its course around the cerebral peduncle up to the orbit, an average of 54 (±4) mm. Opening the infratrochlear triangle revealed the VI nerve intracavernously and under Gruber's ligament, and the extended petrosectomy allowed us to see its cisternal portion (27 ± 6 mm). The trigeminal root was completely visible and so were its three branches (46 ± 2, 34 ± 3, and 31 ± 1 mm, respectively). Conclusion Comprehensive anatomic knowledge and extensive surgical expertise are required when addressing the CS. The transorbital corridor exposes most of the cisternal and the complete cavernous course of involved cranial nerves. This anatomical article helps understanding relations of neural, vascular, and dural structures involved in the CS approach, essential to culminating the learning process of transorbital surgery.
Collapse
Affiliation(s)
- Alejandra Mosteiro
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Marta Codes
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Roberto Tafuto
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università Degli Studi di Napoli “Federico II”, Naples, Italy
| | - Roberto Manfrellotti
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
- Division of Neurosurgery, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza, Italy
| | - Jorge Torales
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
- Department of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Alberto Di Somma
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
- Department of Neurological Surgery, 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
| |
Collapse
|
2
|
Kwon SM, Na MK, Choi KS, Byoun HS, Nam YS. Cadaveric analysis of transcranial versus endoscopic transorbital petrosectomy: comparison of surgical maneuverability and brainstem exposure. Front Oncol 2023; 13:1186012. [PMID: 37483499 PMCID: PMC10359478 DOI: 10.3389/fonc.2023.1186012] [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: 03/14/2023] [Accepted: 06/23/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction While accessing the posterior fossa, the anterior transpetrosal approach (ATPA) and endoscopic transorbital approach (ETOA) use the same bony landmarks during petrous apex drilling. However, owing to their contrasting surgical axes, they are expected to show differences in surgical view, maneuverability, and clinical implications. This study aimed to investigate the feasibility of ETOA in accessing the brainstem and to compare the surgical view and maneuverability of each approach. Methods ATPA and ETOA were performed in four human cadaveric heads (eight sides and four sides in each procedure). The angle of attack (AOA) and surgical depth were measured at the target of interest (root exit zone [REZ] of cranial nerve [CN] V, VI, and VII). When measuring the area of exposure, the brainstem was divided into two areas (anterior and lateral brainstem) based on the longitudinal line crossing the entry zone of the trigeminal root, and the area of each was measured. Results ATPA showed significantly greater value at the trigeminal REZ in both vertical (31.8 ± 6.7° vs. 14.3 ± 5.3°, p=0.006) and horizontal AOA (48.5 ± 2.9° vs. 15.0 ± 5.2°, p<0.001) than ETOA. The AOA at facial REZ was also greater in ATPA than ETOA (vertical, 27.5 ± 3.9° vs. 8.3 ± 3.3°, p<0.001; horizontal, 33.8 ± 2.2° vs. 11.8 ± 2.9°, p<0.001). ATPA presented significantly shorter surgical depth (CN V, 5.8 ± 0.5 cm vs. 9.0 ± 0.8, p<0.001; CN VII, 6.3 ± 0.5 cm vs. 9.5 ± 1.0, p=0.001) than ETOA. The mean area of brainstem exposure did not differ between the two approaches. However, ATPA showed significantly better exposure of anterior brainstem than ETOA (240.7 ± 9.6 mm2 vs. 171.7 ± 15.0 mm2, p<0.001), while ETOA demonstrated better lateral brainstem exposure (174.2 ± 29.1 mm2 vs. 231.1 ± 13.6 mm2, p=0.022). Conclusions ETOA could be a valid surgical option, in selected cases, that provides a direct ventral route to the brainstem. Compared with ATPA, ETOA showed less surgical maneuverability, AOA and longer surgical depth; however, it presented comparable brainstem exposure and better exposure of the lateral brainstem.
Collapse
Affiliation(s)
- Sae Min Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Min Kyun Na
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Hyoung Soo Byoun
- Department of Neurosurgery, Chungnam National University Sejong Hospital, Sejong, Republic of Korea
| | - Yong Seok Nam
- Department of Anatomy, College of Korean Medicine, Dongshin University, Naju, Republic of Korea
| |
Collapse
|
3
|
Frontera NL, Rosado-Philippi J, Díaz FDV, Díaz AS, Medina AV, Figueroa A, González N, Pradilla G, Garzón T, Rodríguez J, Tarrats L, Valle MMD. TransOrbital NeuroEndoscopic Surgery for Biopsy of the Left Cavernous Sinus: A Literature Review, Case Report, and Cadaveric Proof of Concept. J Neurol Surg Rep 2023; 84:e116-e123. [PMID: 37771654 PMCID: PMC10533359 DOI: 10.1055/a-2155-2419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/03/2023] [Indexed: 09/30/2023] Open
Abstract
The aim of this report is to describe TransOrbital NeuroEndoscopic Surgery (TONES) as a safe alternative for obtaining a cavernous sinus (CS) biopsy. We describe this technique in a patient with a diffuse large B cell lymphoma mimicking Tolosa-Hunt's syndrome. Articles were gathered querying PubMed, Embase, and Scopus databases with terms related to a "transorbital neuroendoscopic approach." The literature search was performed by two independent authors (N.L.F. and J.R.), with inconsistencies resolved by the senior author (M.M.D.V.). After screening abstracts for relevance, full-length articles were reviewed for pertinent variables. A comparison was conducted with the illustrative case of a 69-year-old woman who presented to the emergency department with vertigo, ophthalmoplegia, and diplopia for 2 months. A brain magnetic resonance imaging revealed an infiltrative lesion at the left CS. A presumptive diagnosis of Tolosa-Hunt syndrome was made, but a confirmatory biopsy was performed using TONES. Based on our cadaveric study, literature review, and case report, the TONES approach was safe, effective for tissue diagnosis, and associated with minor morbidity and reduced hospital stay. Additional prospective studies are required to study its viability and safety in a larger group of patients.
Collapse
Affiliation(s)
- Natasha L. Frontera
- School of Medicine, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Julio Rosado-Philippi
- School of Medicine, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | | | - Alejandra Santiago Díaz
- School of Medicine, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Adriana Vázquez Medina
- School of Medicine, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Arnaldo Figueroa
- School of Medicine, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Natalia González
- School of Medicine, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University, Atlanta, Georgia, United States
| | - Tomas Garzón
- Department of Neurosurgery, Emory University, Atlanta, Georgia, United States
| | - Julio Rodríguez
- Department of Neurosurgery, Emory University, Atlanta, Georgia, United States
| | - Luisam Tarrats
- School of Medicine, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| | - Miguel Mayol del Valle
- School of Medicine, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico
| |
Collapse
|
4
|
García-Pérez D, Abarca J, González-López P, Nieto J, Lagares A, Paredes I. A Frontal Route to Middle and Posterior Cranial Fossa: Quantitative Study for the Lateral Transorbital Endoscopic Approach and Comparison with the Subtemporal Approach. World Neurosurg 2022; 167:e236-e250. [PMID: 35944860 DOI: 10.1016/j.wneu.2022.07.129] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Skull base lesions within the middle cranial fossa (MCF) remain challenging. Recent reports suggest that transorbital endoscopic approaches (TOEAs) might be particularly suitable to access the MCF and expose the lateral wall of the cavernous sinus and the Meckel's cave. METHODS The present study was developed to compare the nuances of the subtemporal approach (STA) with those of the lateral TOEA (LTOEA) to the MCF and posterior cranial fossa (PCF) in cadaveric specimens. After orbital craniectomy, interdural opening of the cavernous sinus lateral wall (CSlw), exposure of the Gasserian ganglion, and extradural elevation of the temporal lobe was performed. Next, anterior endoscopic petrosectomy was performed and the PCF was accessed. We quantitatively analyzed and compared the angles of attack and distances between LTOEA and STA to different structures at the CSlw, petrous apex (PA), and PCF. RESULTS Cadaveric dissection through the LTOEA completely exposed the CSlw and PA. LTOA exhibited larger distances than the STA to all targets. Importantly, these differences were greater at the PA and its surrounding key anatomic landmarks. The horizontal and vertical angles of attack allowed by the LTOA were smaller both for the CSlw and PA. However, these differences were not significant for the vertical angle of attack at the CSlw. CONCLUSIONS LTOEA provides a direct ventral route to the medial aspect of MCF, PA, and PCF. Although TOEAs are versatile approaches, the unfamiliar surgical anatomy and limited instrument maneuverability demand extensive cadaveric dissection before moving to the clinical setting.
Collapse
Affiliation(s)
- Daniel García-Pérez
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain.
| | - Javier Abarca
- Department of Neurosurgery, University General Hospital of Alicante, Alicante, Spain
| | - Pablo González-López
- Department of Neurosurgery, University General Hospital of Alicante, Alicante, Spain
| | - Juan Nieto
- Department of Neurosurgery, University General Hospital of Alicante, Alicante, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain
| | - Igor Paredes
- Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain
| |
Collapse
|
5
|
Dallan I, Cristofani-Mencacci L, Fiacchini G, Turri-Zanoni M, van Furth W, de Notaris M, Picariello M, Alexandre E, Georgalas C, Bruschini L. Endoscopic-assisted transorbital surgery: Where do we stand on the scott’s parabola? personal considerations after a 10-year experience. Front Oncol 2022; 12:937818. [PMID: 35912254 PMCID: PMC9334664 DOI: 10.3389/fonc.2022.937818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/24/2022] [Indexed: 11/23/2022] Open
Abstract
Transorbital approaches are genuinely versatile surgical routes which show interesting potentials in skull base surgery. Given their “new” trajectory, they can be a very useful adjunct to traditional routes, even being a valid alternative to them in some cases, and add valuable opportunities in selected patients. Indications are constantly expanding, and currently include selected intraorbital, skull base and even intra-axial lesions, both benign and malignant. Given their relatively recent development and thus unfamiliarity among the skull base community, achieving adequate proficiency needs not only a personalized training and knowledge but also, above all, an adequate case volume and a dedicated setting. Current, but mostly future, applications should be selected by genetic, omics and biological features and applied in the context of a truly multidisciplinary environment.
Collapse
Affiliation(s)
- Iacopo Dallan
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
| | - Lodovica Cristofani-Mencacci
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
- *Correspondence: Lodovica Cristofani-Mencacci,
| | - Giacomo Fiacchini
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
| | - Mario Turri-Zanoni
- ENT Unit, Department of Biotechnology and Life Sciences, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Wouter van Furth
- Neurosurgery Unit, Department of Ophthalmology, Leiden University Medical Center, Leiden, Netherlands
| | - Matteo de Notaris
- Neurosurgery Operative Unit, Department of Neuroscience, “San Pio” Hospital, Benevento, Italy
| | - Miriana Picariello
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
| | - Enrico Alexandre
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
| | | | - Luca Bruschini
- Ear Nose Throat (ENT) Audiology and Phoniatric Unit, Department of Surgical Pathology, Medical, Molecular and Critical Area, AziendaOspedaliero-UniversitariaPisana, University of Pisa, Pisa, Italy
| |
Collapse
|
6
|
Houlihan LM, Staudinger Knoll AJ, Kakodkar P, Zhao X, O'Sullivan MGJ, Lawton MT, Preul MC. Transorbital Neuroendoscopic Surgery as a Mainstream Neurosurgical Corridor: A Systematic Review. World Neurosurg 2021; 152:167-179.e4. [PMID: 33940270 DOI: 10.1016/j.wneu.2021.04.104] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transorbital neuroendoscopic surgery (TONES) offers a new level of minimally invasive, minimally disfiguring skull base surgery with maximal surgical visualization. METHODS This review systematically assesses the body of published anatomic (cadaveric) and clinical evidence for the approach. PubMed, Cochrane Library, Ovid MEDLINE, and Embase were systematically searched for articles in which the TONES surgical technique was used in an anatomic, clinical, or combined study. The outcomes of interest included identification of the diseases, operative outcomes, and complication rates. RESULTS Twenty-three articles were selected for this systematic review: 10 were purely anatomic, 10 were clinical, and 3 had both clinical and cadaveric components. The articles reported 69 patients undergoing transorbital or combined transorbital and transnasal intervention. A total of 30 cases of cerebrospinal fluid leak were documented; of these, 28 (93%) had successful resolution, 2 (7%) had recurrence, and 5 (15%) experienced complications. A total of 31 tumors were biopsied (n = 1), resected (n = 22), or debulked (n = 8). Meningiomas were the most common lesion managed via TONES, with 5 of 7 patients with meningioma who reported preoperative neurologic deficits experiencing an improvement in extraocular movement impairment, visual acuity, proptosis, and ptosis. Transient postoperative clinical sequelae, including diplopia and ptosis, were increasingly associated with the superior lid crease incision and the sole transorbital approach. CONCLUSIONS TONES is a significant development in transorbital skull base surgery. However, comprehensive, robust, comparative analyses and increasing use and generalizability of this technique in skull base surgery are awaited.
Collapse
Affiliation(s)
- Lena Mary Houlihan
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | - Pramath Kakodkar
- School of Medicine National University of Galway, Galway, Ireland
| | - Xiaochun Zhao
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | - Michael T Lawton
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark C Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
| |
Collapse
|