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Giammattei L, Starnoni D, Peters D, George M, Messerer M, Daniel RT. Combined petrosal approach: a systematic review and meta-analysis of surgical complications. Neurosurg Rev 2023; 46:172. [PMID: 37439884 PMCID: PMC10344984 DOI: 10.1007/s10143-023-02072-7] [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: 05/09/2023] [Revised: 05/31/2023] [Accepted: 06/20/2023] [Indexed: 07/14/2023]
Abstract
Transpetrosal approaches are known to be associated with a significant risk of complications, including CSF leak, facial palsy, hearing impairment, venous injury, and/or temporal lobe injury. We aimed to evaluate the morbidity of the standard combined petrosal approach (CPA), defined as a combination of the posterior (retrolabyrinthine) and the anterior petrosal approach. We performed a systematic review and meta-analysis of articles reporting on clinical series of patients operated on for petroclival meningiomas through CPA. Studies that used the terminology "combined petrosal approach" without matching the aforementioned definition were excluded as well as clinical series that included less than 5 patients. A total of 8 studies were included involving 160 patients. The pooled complication rates were 3% (95% CI, 0.5-5.6) for CSF leak, 8.6% (95% CI, 4.1-13.2%) for facial palsy, 8.2% (95% CI, 3.9-12.6%) for hearing impairment, 2.8% (95% CI, 0.9-6.5%) for venous complications, and finally 4.8% (95%, 1.2-8.4%) for temporal lobe injury. Contrary to the general belief, CPA is associated with an acceptable rate of complications, especially when compared to alternative approaches to the petroclival area. In view of the major advantages like shorter trajectory, multiple angles of surgical attack, and early tumor devascularization, CPA remains an important tool in the armamentarium of the skull base surgeon.
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Affiliation(s)
- L Giammattei
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland.
| | - D Starnoni
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - D Peters
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
- Carolina Neurosurgery & Spine Associates, Charlotte, NC, USA
| | - M George
- Department of Otorhinolaryngology and Head and Neck Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - M Messerer
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - R T Daniel
- Department of Neurosurgery, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Farina D, Pessina C, Sozzi F, Lombardi D, Renzulli M, Borghesi A, Ravanelli M, Maroldi R. Anterior and Central Skull Base Tumors: Key Points for the Radiologist to Analyze Prior to Endoscopic Approaches. Neuroimaging Clin N Am 2021; 31:433-449. [PMID: 34689926 DOI: 10.1016/j.nic.2021.05.005] [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: 10/20/2022]
Abstract
Initially developed as a minimally invasive technique to approach inflammatory conditions, transnasal endoscopic surgery has progressively expanded its anatomic targets and clinical indications. Consequently, numerous surgical approaches to the anterior and central skull base were developed, referred to as extended endonasal approaches (EEA). The intrinsic advantage of EEA is the exploitation of a natural corridor provided by sinonasal airspaces, with no need for skin incision and osteotomy and limited soft tissue damage. In this context, imaging plays essential role, demonstrating the relevant anatomic relationships of the lesion, the proper surgical corridor, the anatomic variants that may increase the surgical risk.
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Affiliation(s)
- Davide Farina
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Viale Europa 11, 25123 Brescia, Italy.
| | - Carlotta Pessina
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Viale Europa 11, 25123 Brescia, Italy
| | - Federica Sozzi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Viale Europa 11, 25123 Brescia, Italy
| | - Davide Lombardi
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Brescia, P.zzale Spedali Civili 1, 25123 Brescia, Italy
| | - Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy
| | - Andrea Borghesi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Viale Europa 11, 25123 Brescia, Italy
| | - Marco Ravanelli
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Viale Europa 11, 25123 Brescia, Italy
| | - Roberto Maroldi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Viale Europa 11, 25123 Brescia, Italy
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Shin M, Hasegawa H, Miyawaki S, Kakigi A, Takizawa T, Kondo K, Shiode T, Kin T, Saito N. Endoscopic transmastoid posterior petrosal approach for locally aggressive tumors in the petrous part of the temporal bone involving the internal auditory canal, jugular foramen, and hypoglossal canal. J Neurosurg 2020; 133:1248-1260. [PMID: 31561213 DOI: 10.3171/2019.5.jns19187] [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: 01/21/2019] [Accepted: 05/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The posterior petrosal approach is an established surgical method offering wide access to skull base lesions through mastoid air cells. The authors describe their experience with the endoscopic transmastoid "posterior petrosal" approach (EPPAP) for skull base tumors involving the internal auditory canal (IAC), jugular foramen, and hypoglossal canal. METHODS The EPPAP was performed for 7 tumors (3 chordomas, 2 chondrosarcomas, 1 schwannoma, and 1 solitary fibrous tumor). All surgical procedures were performed under endoscopic visualization with mastoidectomy. The compact bone of the mastoid air cells and posterior surface of the petrous bone are carefully removed behind the semicircular canals. When removal of cancellous bone is extended superomedially through the infralabyrinthine space, the surgeon can expose the IAC and petrous portion of the internal carotid artery to reach the petrous apex (infralabyrinthine route). When removal of cancellous bone is extended inferomedially along the sigmoid sinus, the surgeon can safely reach the jugular foramen (transjugular route). Drilling of the inferior surface of petrous bone is extended further inferoposteriorly behind the jugular bulb to approach the hypoglossal canal and parapharyngeal space through the lateral aspect of the occipital condyle (infrajugular route). RESULTS Of the 7 tumors, gross-total resection was achieved in 4 (57.1%), subtotal resection (> 95% removal) in 2 (28.6%), and partial resection (90% removal) in 1 (14.2%). Postoperatively, 2 of 3 patients with exudative otitis media showed improvement of hearing deterioration, as did 2 patients with tinnitus. Hypoglossal nerve palsy and swallowing difficulty were improved after surgery in 2 patients and 1 patient, respectively. In 1 patient with severe cranial nerve deficits before surgery, symptoms did not show any improvement. CONCLUSIONS The authors present their preliminary experience with EPPAP for skull base tumors in the petrous part of the temporal bone and the lateral part of the occipital condyle involving the cranial nerves and internal carotid arteries. The microscope showed a higher-quality image and illumination in the low-power field. However, the endoscope could offer wider visualization of the surgical field and contribute to minimizing the size of the surgical pathways, necessity of brain retraction, and eventually the invasiveness of surgery. Thus, the EPPAP may be safe and effective for skull base tumors in the petrous region, achieving balance between the radicality and invasiveness of the skull base surgery.
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Affiliation(s)
| | | | | | - Akinobu Kakigi
- 2Otolaryngology, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Kenji Kondo
- 2Otolaryngology, The University of Tokyo Hospital, Tokyo, Japan
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Mooney MA, Cavallo C, Belykh E, Gandhi S, Mascitelli J, Preul MC, Stevens S, Almefty KK, Lawton MT. Posterior Petrosal Transotic Approach for Cerebellopontine Angle Hemangioblastoma: Technical Case Report. Oper Neurosurg (Hagerstown) 2019; 17:E269-E273. [PMID: 31329951 DOI: 10.1093/ons/opz058] [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: 05/10/2018] [Accepted: 02/28/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Although posterior petrosal approaches are utilized less frequently in many practices today, they continue to provide distinct surgical advantages in carefully selected cases. Here, we report a case of a recurrent cerebellopontine angle (CPA) hemangioblastoma that had failed a prior, more conservative, surgical approach. We provide cadaveric dissections of variations of posterior petrosal approaches to illustrate the advantages of the selected approach. CLINICAL PRESENTATION A 70-yr-old female presented with a growing left CPA hemangioblastoma. The lesion had undergone a prior subtotal resection from a retrosigmoid approach and subsequent adjuvant radiation treatment. The patient had worsening left facial strength, progressive balance difficulty, and absent left auditory function. Preoperative angiogram demonstrated arterial blood supply from the left anterior inferior cerebellar artery (AICA) that was deemed unsafe for embolization due to significant arteriovenous shunting. A posterior petrosal transotic approach was performed in order to optimize the working angle to the anterior brainstem and afford the ability to occlude the vascular supply from AICA prior to surgical resection of the lesion. CONCLUSION The posterior petrosal transotic approach offers an improved surgical working angle to the anterior brainstem compared to the translabyrinthine approach. This advantage can be particularly important with vascular tumors that receive blood supply anteriorly, as in this case from AICA, and can improve the safety of the resection.
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Affiliation(s)
- Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Claudio Cavallo
- 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
| | - Sirin Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Justin Mascitelli
- 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
| | - Shawn Stevens
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Kaith K Almefty
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Extended Retro/Infralabyrinthine Approach to Cerebellopontine Angle and Internal Auditory Canal, a Radio-Anatomic Study. Otol Neurotol 2019; 40:e646-e652. [PMID: 31135679 DOI: 10.1097/mao.0000000000002260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION There is a considerable controversy about approaches that preserve hearing in acoustic neuroma surgery. Transtemporal approaches have the advantage of extradural drilling and minimal cerebellar retraction. We aimed to measure the limits and exposure of extended infra/retrolabyrinthine approach using temporal bone dissection and temporal high resolution computed tomography (HRCT). MATERIALS AND METHODS Hundred temporal bone sides (unpaired) underwent HRCT. The images were used to estimate the limits and exposure of infra/retrolabyrinthine approach. Also, 10 temporal bone sides underwent the same imaging protocol then were dissected to measure actual exposure and limits of dissection. These measures were compared with those retrieved by HRCT to find if they are appropriate to be applied in general population. RESULTS Mean posterior fossa angle of vision (24.5 degrees), retrolabyrinthine (internal auditory canal) IAC (58.6%), and infralabyrinthine IAC exposures (73.2%) were documented based on data retrieved from CT scan. After temporal bone dissection, posterior fossa (p = 0.139) and infralabyrinthine exposures (p = 0.674) were not statistically different comparing with measures retrieved from CT scan; however, retrolabyrinthine exposure was overestimated (p = 0.012). CONCLUSION We found that at least 20% more of IAC length can be exposed by extension of retrolabyrinthine to infralabyrinthine dissection. Infralabyrinthine exposure can be estimated preoperatively using temporal bone CT but the same is not true for retrolabyrinthine exposure.
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Ostergard TA, Glenn CA, Dekker SE, Pace JR, Bambakidis NC. Retrosigmoid Transtentorial Approach: Technical Nuances and Quantification of Benefit From Tentorial Incision. World Neurosurg 2018; 119:176-182. [PMID: 30092467 DOI: 10.1016/j.wneu.2018.07.259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 07/27/2018] [Accepted: 07/28/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The transtentorial extension of the retrosigmoid approach allows for improved visualization of the brainstem and petroclival region. This approach is an important tool in the skull base surgeon's armamentarium for pathologies involving the petroclival region. It has been shown that the addition of tentorial transection improves the exposed surface area of the brainstem. However, no data have been reported regarding the depth of the additional anterior and medial exposure. The goal of the present study was to describe the additional depth of exposure gained by performing tentorial transection. This information allows surgeons to preoperatively estimate the amount of operative exposure gained by this technique. METHODS Five preserved cadaveric heads were dissected using frameless image guidance. A standard retrosigmoid craniotomy was performed, followed by tentorial transection. The boundaries of the surgical exposure and depth of the surgical field were compared before and after tentorial transection. RESULTS After transection, we found a 20.1-mm increase in anterior exposure (P < 0.01) and a 13-mm increase in medial exposure (P < 0.01). No significant difference was found in the extent of the superior (P = 0.32) or lateral (P = 0.07) exposure. The surgical working distance increased significantly from 68.8 to 90.3 mm (P < 0.01). CONCLUSIONS When performing retrosigmoid craniotomy, the addition of tentorial transection allows for a significant increase in anterior and medial exposure with no significant increase in superior or lateral exposure.
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Affiliation(s)
- Thomas A Ostergard
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.
| | - Chad A Glenn
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Simone E Dekker
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Jonathan R Pace
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Nicholas C Bambakidis
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
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