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Ferlendis L, Bossi B, Barillot C, Leocata A, Veiceschi P, Pozzi F, Castelnuovo P, Locatelli D. Endoscopic Transpterygoid Approach to Meckel's Cave: Technical Considerations and Retrospective Analysis of a Clinical Series. Clin Neurol Neurosurg 2024; 243:108382. [PMID: 38944020 DOI: 10.1016/j.clineuro.2024.108382] [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: 03/15/2024] [Revised: 05/06/2024] [Accepted: 06/08/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVE Tumors located within the Meckel's cave (MC) pose a significant surgical challenge. Although several corridors to access this complex region have been described, the endoscopic transpterygoid approach (ETPA) and the endoscopic transorbital superior eyelid approach (ETOA) have emerged in recent years, as viable alternatives to traditional microsurgical transcranial approaches (MTA). To date, there is a limited literature on surgical series considering endoscopic-assisted approaches to the MC. METHODS We conducted a retrospective analysis of patients with primary MC tumors treated at our Institution between 2015 and 2022, specifically those managed via the ETPA assisted by intraoperative Endoscopic Diving Technique (EDT). Lesion resection extent was evaluated using pre- and post-intervention radiological images and surgical videos. Moreover, a literature review on ETPA was performed. RESULTS This series comprises 7 patients affected by 4 trigeminal schwannomas, 1 benign notochordal cell tumor, 1 dermoid cyst and 1 mesenchymal tumor. In 71 % of cases, trigeminal neuralgia was the presenting symptom. Post-operative clinical improvement was observed in all but one case. Notably, 85.7 % of patients achieved total or near-total resection (NTR), with the remaining case undergoing subtotal resection (STR). No significant intraoperative complications occurred, and no recurrences were observed during the mean follow-up period of 41 months. CONCLUSIONS In selected cases, the ETPA offers a direct and safe path to lesions located into the MC. This approach circumvents complications and constraints associated with ETOA or MTA. Moreover, the use of the EDT reduces manipulation of critical neurovascular structures, enhancing the efficacy of the ETPA.
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Affiliation(s)
- Luca Ferlendis
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy.
| | - Bianca Bossi
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Cedric Barillot
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Antonio Leocata
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Pierlorenzo Veiceschi
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Fabio Pozzi
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Paolo Castelnuovo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
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Zanin L, Agosti E, Ebner F, de Maria L, Belotti F, Buffoli B, Rezzani R, Hirt B, Ravanelli M, Ius T, Zeppieri M, Tatagiba MS, Fontanella MM, Doglietto F. Quantitative Anatomical Comparison of Surgical Approaches to Meckel's Cave. J Clin Med 2023; 12:6847. [PMID: 37959312 PMCID: PMC10648058 DOI: 10.3390/jcm12216847] [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: 10/08/2023] [Revised: 10/27/2023] [Accepted: 10/28/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Meckel's cave is a challenging surgical target due to its deep location and proximity to vital neurovascular structures. Surgeons have developed various microsurgical transcranial approaches (MTAs) to access it, but there is no consensus on the best method. Newer endoscopic approaches have also emerged. This study seeks to quantitatively compare these surgical approaches to Meckel's cave, offering insights into surgical volumes and exposure areas. METHODS Fifteen surgical approaches were performed bilaterally in six specimens, including the pterional approach (PTA), fronto-temporal-orbito-zygomatic approach (FTOZA), subtemporal approach (STA), Kawase approach (KWA), retrosigmoid approach (RSA), retrosigmoid approach with suprameatal extension (RSAS), endoscopic endonasal transpterygoid approach (EETPA), inferolateral transorbital approach (ILTEA) and superior eyelid approach (SEYA). All the MTAs were performed both with 10 mm and 15 mm of brain retraction, to consider different percentages of surface exposure. A dedicated navigation system was used to quantify the surgical working volumes and exposure of different areas of Meckel's cave (ApproachViewer, part of GTx-Eyes II, University Health Network, Toronto, Canada). Microsurgical transcranial approaches were quantified with two different degrees of brain retraction (10 mm and 15 mm). Statistical analysis was performed using a mixed linear model with bootstrap resampling. RESULTS The RSAS with 15 mm of retraction offered the maximum exposure of the trigeminal stem (TS). If compared to the KWA, the RSA exposed more of the TS (69% vs. 46%; p = 0.01). The EETPA and ILTEA exposed the Gasserian ganglion (GG) mainly in the anteromedial portion, but with a significant 20% gain in exposure provided by the EETPA compared to ILTEA (42% vs. 22%; p = 0.06). The STA with 15 mm of retraction offered the maximum exposure of the GG, with a significant gain in exposure compared to the STA with 10 mm of retraction (50% vs. 35%; p = 0.03). The medial part of the three trigeminal branches was mainly exposed by the EETPA, particularly for the ophthalmic (66%) and maxillary (83%) nerves. The EETPA offered the maximum exposure of the medial part of the mandibular nerve, with a significant gain in exposure compared to the ILTEA (42% vs. 11%; p = 0.01) and the SEY (42% vs. 2%; p = 0.01). The FTOZA offered the maximum exposure of the lateral part of the ophthalmic nerve, with a significant gain of 67% (p = 0.03) and 48% (p = 0.04) in exposure compared to the PTA and STA, respectively. The STA with 15 mm of retraction offered the maximum exposure of the lateral part of the maxillary nerve, with a significant gain in exposure compared to the STA with 10 mm of retraction (58% vs. 45%; p = 0.04). The STA with 15 mm of retraction provided a significant exposure gain of 23% for the lateral part of the mandibular nerve compared to FTOZA with 15 mm of retraction (p = 0.03). CONCLUSIONS The endoscopic approaches, through the endonasal and transorbital routes, can provide adequate exposure of Meckel's cave, especially for its more medial portions, bypassing the impediment of major neurovascular structures and significant brain retraction. As far as the most lateral portion of Meckel's cave, MTA approaches still seem to be the gold standard in obtaining optimal exposure and adequate surgical volumes.
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Affiliation(s)
- Luca Zanin
- Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy (E.A.)
| | - Edoardo Agosti
- Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy (E.A.)
| | - Florian Ebner
- Department of Neurological Surgery, Eberhard-Karls University, Tübingen University Hospital, D-72076 Tübingen, Germany
| | - Lucio de Maria
- Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy (E.A.)
| | - Francesco Belotti
- Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy (E.A.)
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy
| | - Rita Rezzani
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy
| | - Bernard Hirt
- Department of Clinical Anatomy, Eberhard-Karls-University, Tübingen University Hospital, D-72076 Tübingen, Germany
| | - Marco Ravanelli
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy
| | - Tamara Ius
- Neurosurgery Unit, Head-Neck and NeuroScience Department, University Hospital of Udine, p.le S. Maria della Misericordia 15, 33100 Udine, Italy
| | - Marco Zeppieri
- Department of Ophthalmology, University Hospital of Udine, p.le S. Maria della Misericordia 15, 33100 Udine, Italy
| | - Marcos Soares Tatagiba
- Department of Neurological Surgery, Eberhard-Karls University, Tübingen University Hospital, D-72076 Tübingen, Germany
| | - Marco Maria Fontanella
- Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy (E.A.)
| | - Francesco Doglietto
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
- Neurosurgery, Università Cattolica del Sacro Cuore, 20123 Rome, Italy
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de Notaris M, Sacco M, Corrivetti F, Grasso M, Corvino S, Piazza A, Kong DS, Iaconetta G. The Transorbital Approach, A Game-Changer in Neurosurgery: A Guide to Safe and Reliable Surgery Based on Anatomical Principles. J Clin Med 2023; 12:6484. [PMID: 37892624 PMCID: PMC10607762 DOI: 10.3390/jcm12206484] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
During the last few years, the superior eyelid endoscopic transorbital approach has been proposed as a new minimally invasive pathway to access skull base lesions, mostly in ophthalmologic, otolaryngologic, and maxillofacial surgeries. However, most neurosurgeons performing minimally invasive endoscopic neurosurgery do not usually employ the orbit as a surgical corridor. The authors undertook this technical and anatomical study to contribute a neurosurgical perspective, exploring the different possibilities of this novel route. Ten dissections were performed on ten formalin-fixed specimens to further refine the transorbital technique. As part of the study, the authors also report an illustrative transorbital surgery case to further detail key surgical landmarks. Herein, we would like to discuss equipment, key anatomical landmarks, and surgical skills and stress the steps and details to ensure a safe and successful procedure. We believe it could be critical to promote and encourage the neurosurgical community to overcome difficulties and ensure a successful surgery by following these key recommendations.
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Affiliation(s)
- Matteo de Notaris
- Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, 84125 Salerno, Italy
- Department of Neuroscience, Neurosurgery Operative Unit, “San Pio” Hospital, 82100 Benevento, Italy
| | - Matteo Sacco
- Department of Neurosurgery, University of Foggia, 71122 Foggia, Italy
| | - Francesco Corrivetti
- Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, 84125 Salerno, Italy
| | - Michele Grasso
- Department of Surgery, Otorhinolaryngology Operative Unit, “San Pio” Hospital, 82100 Benevento, Italy
| | - Sergio Corvino
- Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, 84125 Salerno, Italy
- Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, 80055 Naples, Italy
| | - Amedeo Piazza
- Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, 84125 Salerno, Italy
- Department of Neurosurgery, Sapienza University, 00185 Rome, Italy
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06531, Republic of Korea
| | - Giorgio Iaconetta
- Unit of Neurosurgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, University of Salerno, 84084 Salerno, Italy
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Agosti E, Zeppieri M, De Maria L, Mangili M, Rapisarda A, Ius T, Spadea L, Salati C, Tel A, Pontoriero A, Pergolizzi S, Angileri FF, Fontanella MM, Panciani PP. Surgical Treatment of Spheno-Orbital Meningiomas: A Systematic Review and Meta-Analysis of Surgical Techniques and Outcomes. J Clin Med 2023; 12:5840. [PMID: 37762781 PMCID: PMC10531637 DOI: 10.3390/jcm12185840] [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: 07/21/2023] [Revised: 08/29/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Spheno-orbital meningiomas (SOMs) are rare tumors arising from the meninges surrounding the sphenoid bone and orbital structures. Surgical resection is the primary treatment approach for SOMs. Several surgical approaches have been described during the decades, including microsurgical transcranial (MTAs), endoscopic endonasal (EEAs), endoscopic transorbital (ETOAs), and combined approaches, and the choice of surgical approach remains a topic of debate. PURPOSE This systematic review and meta-analysis aim to compare the clinical and surgical outcomes of different surgical approaches used for the treatment of SOMs, discussing surgical techniques, outcomes, and factors influencing surgical decision making. METHODS A comprehensive literature review of the databases PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted for articles published on the role of surgery for the treatment of SOMs until 2023. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Meta-analysis was performed to estimate pooled event rates and assess heterogeneity. Fixed- and random-effects were used to assess 95% confidential intervals (CIs) of presenting symptoms, outcomes, and complications. RESULTS A total of 59 studies comprising 1903 patients were included in the systematic review and meta-analysis. Gross total resection (GTR) rates ranged from 23.5% for ETOAs to 59.8% for MTAs. Overall recurrence rate after surgery was 20.7%. Progression-free survival (PFS) rates at 5 and 10 years were 75.5% and 49.1%, respectively. Visual acuity and proptosis improvement rates were 57.5% and 79.3%, respectively. Postoperative cranial nerve (CN) focal deficits were observed in 20.6% of cases. The overall cerebro-spinal fluid (CSF) leak rate was 3.9%, and other complications occurred in 13.9% of cases. MTAs showed the highest GTR rates (59.8%, 95%CI = 49.5-70.2%; p = 0.001) but were associated with increased CN deficits (21.0%, 95%CI = 14.5-27.6%). ETOAs had the lowest GTR rates (23.5%, 95%CI = 0.0-52.5%; p = 0.001), while combined ETOA and EEA had the highest CSF leak rates (20.3%, 95%CI = 0.0-46.7%; p = 0.551). ETOAs were associated with better proptosis improvement (79.4%, 95%CI = 57.3-100%; p = 0.002), while anatomical class I lesions were associated with better visual acuity (71.5%, 95%CI = 63.7-79.4; p = 0.003) and proptosis (60.1%, 95%CI = 38.0-82.2; p = 0.001) recovery. No significant differences were found in PFS rates between surgical approaches. CONCLUSION Surgical treatment of SOMs aims to preserve visual function and improve proptosis. Different surgical approaches offer varying rates of GTR, complications, and functional outcomes. A multidisciplinary approach involving a skull base team is crucial for optimizing patient outcomes.
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Affiliation(s)
- Edoardo Agosti
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (E.A.)
| | - Marco Zeppieri
- Department of Ophthalmology, University Hospital of Udine, Piazzale S. Maria Della Misericordia 15, 33100 Udine, Italy
| | - Lucio De Maria
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (E.A.)
| | - Marcello Mangili
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (E.A.)
| | - Alessandro Rapisarda
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, 00168 Rome, Italy
| | - Tamara Ius
- Neurosurgery Unit, Head-Neck and NeuroScience Department, University Hospital of Udine, p.le S. Maria Della Misericordia 15, 33100 Udine, Italy
| | - Leopoldo Spadea
- Eye Clinic, Policlinico Umberto I, “Sapienza” University of Rome, 00142 Rome, Italy
| | - Carlo Salati
- Department of Ophthalmology, University Hospital of Udine, Piazzale S. Maria Della Misericordia 15, 33100 Udine, Italy
| | - Alessandro Tel
- Clinic of Maxillofacial Surgery, Head-Neck and NeuroScience Department University Hospital of Udine, p.le S. Maria Della Misericordia 15, 33100 Udine, Italy
| | - Antonio Pontoriero
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, 98125 Messina, Italy
| | - Stefano Pergolizzi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, 98125 Messina, Italy
| | - Filippo Flavio Angileri
- Neurosurgery Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, 98125 Messina, Italy
| | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (E.A.)
| | - Pier Paolo Panciani
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy; (E.A.)
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Zoia C, Mantovani G, Müther M, Suero Molina E, Scerrati A, De Bonis P, Cornelius J, Roche P, Tatagiba M, Jouanneau E, Manet R, Schroeder H, Cavallo L, Kasper E, Meling T, Mazzatenta D, Daniel R, Messerer M, Visocchi M, Froelich S, Bruneau M, Spena G. Through the orbit and beyond: Current state and future perspectives in endoscopic orbital surgery on behalf of the EANS frontiers committee in orbital tumors and the EANS skull base section. BRAIN & SPINE 2023; 3:102669. [PMID: 37720459 PMCID: PMC10500473 DOI: 10.1016/j.bas.2023.102669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/16/2023] [Accepted: 08/25/2023] [Indexed: 09/19/2023]
Abstract
Introduction Orbital surgery has always been disputed among specialists, mainly neurosurgeons, otorhinolaryngologists, maxillofacial surgeons and ophthalmologists. The orbit is a borderland between intra- and extracranial compartments; Krönlein's lateral orbitotomy and the orbitozygomatic infratemporal approach are the historical milestones of modern orbital-cranial surgery. Research question Since its first implementation, endoscopy has significantly impacted neurosurgery, changing perspectives and approaches to the skull base. Since its first application in 2009, transorbital endoscopic surgery opened the way for new surgical scenario, previously feasible only with extensive tissue dissection. Material and methods A PRISMA based literature search was performed to select the most relevant papers on the topic. Results Here, we provide a narrative review on the current state and future trends in endoscopic orbital surgery. Discussion and conclusion This manuscript is a joint effort of the EANS frontiers committee in orbital tumors and the EANS skull base section.
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Affiliation(s)
- C. Zoia
- UOC Neurochirurgia, Ospedale Moriggia Pelascini, Gravedona e Uniti, Italy
| | - G. Mantovani
- Neurosurgery Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - M. Müther
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - E. Suero Molina
- Department of Neurosurgery, University Hospital of Münster, Münster, Germany
| | - A. Scerrati
- Neurosurgery Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - P. De Bonis
- Neurosurgery Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - J.F. Cornelius
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - P.H. Roche
- Department of Neurosurgery, Aix-Marseille Université, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | - M. Tatagiba
- Department of Neurosurgery, University Hospital Tübingen, Tübingen, Germany
| | - E. Jouanneau
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - R. Manet
- Department of Neurosurgery, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - H.W.S. Schroeder
- Department of Neurosurgery, University Medicine Greifswald, Germany
| | - L.M. Cavallo
- Department of Neurosciences and Reproductive and Dental Sciences, Division of Neurosurgery, Federico II University of Naples, Policlinico Federico II University Hospital, Italy
| | - E.M. Kasper
- Department of Neurosurgery, Steward Medical Group, Brighton, USA
| | - T.R. Meling
- Department of Neurosurgery, The National Hospital, Rigshospitalet, Copenhagen, Denmark
| | - D. Mazzatenta
- Department of Neurosurgery, Neurological Sciences Institut IRCCS, Bologna, Italy
| | - R.T. Daniel
- Department of Neurosurgery, Department of Neuroscience, Centre Hospitalier Universitaire Vaudois, University Hospital, Lausanne, Switzerland
| | - M. Messerer
- Department of Neurosurgery, Department of Neuroscience, Centre Hospitalier Universitaire Vaudois, University Hospital, Lausanne, Switzerland
| | - M. Visocchi
- Department of Neurosurgery, Institute of Neurosurgery Catholic University of Rome, Italy
| | - S. Froelich
- Department of Neurosurgery, Lariboisière Hospital, Université Paris Diderot, Paris, France
| | - M. Bruneau
- Department of Neurosurgery, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - G. Spena
- Neurosurgery Unit, IRCSS San Matteo Hospital, Pavia, Italy
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Agosti E, De Maria L, Mattogno PP, Della Pepa GM, D’Onofrio GF, Fiorindi A, Lauretti L, Olivi A, Fontanella MM, Doglietto F. Quantitative Anatomical Studies in Neurosurgery: A Systematic and Critical Review of Research Methods. Life (Basel) 2023; 13:1822. [PMID: 37763226 PMCID: PMC10532642 DOI: 10.3390/life13091822] [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: 07/10/2023] [Revised: 08/17/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The anatomy laboratory can provide the ideal setting for the preclinical phase of neurosurgical research. Our purpose is to comprehensively and critically review the preclinical anatomical quantification methods used in cranial neurosurgery. METHODS A systematic review was conducted following the PRISMA guidelines. The PubMed, Ovid MEDLINE, and Ovid EMBASE databases were searched, yielding 1667 papers. A statistical analysis was performed using R. RESULTS The included studies were published from 1996 to 2023. The risk of bias assessment indicated high-quality studies. Target exposure was the most studied feature (81.7%), mainly with area quantification (64.9%). The surgical corridor was quantified in 60.9% of studies, more commonly with the quantification of the angle of view (60%). Neuronavigation-based methods benefit from quantifying the surgical pyramid features that define a cranial neurosurgical approach and allowing post-dissection data analyses. Direct measurements might diminish the error that is inherent to navigation methods and are useful to collect a small amount of data. CONCLUSION Quantifying neurosurgical approaches in the anatomy laboratory provides an objective assessment of the surgical corridor and target exposure. There is currently limited comparability among quantitative neurosurgical anatomy studies; sharing common research methods will provide comparable data that might also be investigated with artificial intelligence methods.
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Affiliation(s)
- Edoardo Agosti
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
| | - Lucio De Maria
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
- Division of Neurosurgery, Department of Clinical Neuroscience, Geneva University Hospitals (HUG), 1205 Geneva, Switzerland
| | - Pier Paolo Mattogno
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
| | - Giuseppe Maria Della Pepa
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
| | | | - Alessandro Fiorindi
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
| | - Liverana Lauretti
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
| | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
| | - Francesco Doglietto
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
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Serioli S, Agosti E, Buffoli B, Raffetti E, Alexander AY, Salgado-López L, Hirtler L, Rezzani R, Maroldi R, Draghi R, Borghesi I, Calbucci F, Peris-Celda M, Fontanella MM, Doglietto F. Microsurgical transcranial approaches to the posterior surface of petrosal portion of the temporal bone: quantitative analysis of surgical volumes and exposed areas. Neurosurg Rev 2023; 46:48. [PMID: 36745228 DOI: 10.1007/s10143-023-01956-y] [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: 07/13/2022] [Revised: 01/12/2023] [Accepted: 01/24/2023] [Indexed: 02/07/2023]
Abstract
Different microsurgical transcranial approaches (MTAs) have been described to expose the posterior surface of the petrous bone (PPB). A quantitative, anatomical comparison of the most used MTAs, for specific areas of the PPB, is not available. Anatomical dissections were performed on five formalin-fixed, latex-injected cadaver heads (10 sides). Six MTAs were analyzed: Kawase approach (KWA), retrosigmoid approach (RSA), retrosigmoid approach with suprameatal extension (RSAS), retrolabyrinthine approach (RLA), translabyrinthine approach (TLA), and transcochlear approach (TCA). Surgical volumes and exposed areas of each approach were quantified with a dedicated neuronavigation system (ApproachViewer, part of GTx-Eyes II, University Health Network, Toronto, Canada) and adjuvant software (ITK-SNAP and Autodesk Meshmixer 3.5). Areas and volumes were compared using linear mixed models. TCA provided the best exposure of Trautmann's triangle and the retromeatal, suprameatal, meatal, and premeatal regions. RSAs provided the best exposure of the inframeatal region, with RSAS gaining significant exposure of the suprameatal region. KWA had the highest surgical volume, and RLA the lowest. Transpetrosal approaches offer the widest exposure of PPB proportionally to their invasiveness. Retrosigmoid approaches, which get to the studied region through a postero-lateral path, are paramount for the exposure of the inframeatal and suprameatal region and, given the adequate exposure of the remaining PPB, represent an effective approach for the cerebellopontine angle (CPA). These anatomical findings must be considered with approach-related morbidity and the pathological features in order to choose the most appropriate approach in clinical practice.
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Affiliation(s)
- Simona Serioli
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazza Spedali Civili 1, Spedali Civili of Brescia, 25123, Brescia, Italy
- Unit of Neurosurgery, GVM Care&Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazza Spedali Civili 1, Spedali Civili of Brescia, 25123, Brescia, Italy.
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Elena Raffetti
- Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | | | | | - Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Rita Rezzani
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Division of Radiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo Draghi
- Unit of Neurosurgery, GVM Care&Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | - Ignazio Borghesi
- Unit of Neurosurgery, GVM Care&Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | - Fabio Calbucci
- Unit of Neurosurgery, GVM Care&Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | | | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazza Spedali Civili 1, Spedali Civili of Brescia, 25123, Brescia, Italy
| | - Francesco Doglietto
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University School of Medicine, Rome, Italy
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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.
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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
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Agosti E, Saraceno G, Rampinelli V, Raffetti E, Veiceschi P, Buffoli B, Rezzani R, Giorgianni A, Hirtler L, Alexander AY, Deganello A, Piazza C, Nicolai P, Castelnuovo P, Locatelli D, Peris-Celda M, Fontanella MM, Doglietto F. Quantitative Anatomic Comparison of Endoscopic Transnasal and Microsurgical Transcranial Approaches to the Anterior Cranial Fossa. Oper Neurosurg (Hagerstown) 2022; 23:e256-e266. [PMID: 36106936 DOI: 10.1227/ons.0000000000000312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 04/12/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Several microsurgical transcranial approaches (MTAs) and endoscopic transnasal approaches (EEAs) to the anterior cranial fossa (ACF) have been described. OBJECTIVE To provide a preclinical, quantitative, anatomic, comparative analysis of surgical approaches to the ACF. METHODS Five alcohol-fixed specimens underwent high-resolution computed tomography. The following approaches were performed on each specimen: EEAs (transcribriform, transtuberculum, and transplanum), anterior MTAs (transfrontal sinus interhemispheric, frontobasal interhemispheric, and subfrontal with unilateral and bilateral frontal craniotomy), and anterolateral MTAs (supraorbital, minipterional, pterional, and frontotemporal orbitozygomatic approach). An optic neuronavigation system and dedicated software (ApproachViewer, part of GTx-Eyes II-UHN) were used to quantify the working volume of each approach and extrapolate the exposure of different ACF regions. Mixed linear models with random intercepts were used for statistical analyses. RESULTS EEAs offer a large and direct route to the midline region of ACF, whose most anterior structures (ie, crista galli, cribriform plate, and ethmoidal roof) are also well exposed by anterior MTAs, whereas deeper ones (ie, planum sphenoidale and tuberculum sellae) are also well exposed by anterolateral MTAs. The orbital roof region is exposed by both anterolateral and lateral MTAs. The posterolateral region (ie, sphenoid wing and optic canal) is well exposed by anterolateral MTAs. CONCLUSION Anterior and anterolateral MTAs play a pivotal role in the exposure of most anterior and posterolateral ACF regions, respectively, whereas midline regions are well exposed by EEAs. Furthermore, certain anterolateral approaches may be most useful when involvement of the optic canal and nerves involvement are suspected.
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Affiliation(s)
- Edoardo Agosti
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Giorgio Saraceno
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Vittorio Rampinelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Elena Raffetti
- Department of Global Public Health Sciences, Karolinska Institute, Stockholm, Sweden.,Center for Natural Hazards and Disaster Science, Uppsala University, Uppsala, Sweden
| | - Pierlorenzo Veiceschi
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Rita Rezzani
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Andrea Giorgianni
- Department of Neuroradiology, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | | | - Alberto Deganello
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Cesare Piazza
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Section of Otorhinolaryngology-Head and Neck Surgery, University of Padua-Azienda Ospedaliera di Padova, Padua, Italy
| | - Paolo Castelnuovo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria-Varese, ASST Sette Laghi, Ospedale di Circolo, Varese, Italy.,Head and Neck Surgery & Forensic Dissection Research Center, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.,Head and Neck Surgery & Forensic Dissection Research Center, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Maria Peris-Celda
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Doglietto
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Turri-Zanoni M, Arosio AD, Agosti E, Battaglia P, Cherubino M, Balbi S, Margherini S, Locatelli D, Valdatta L, Castelnuovo P. Endoscopic-assisted orbital exenteration: Technical feasibility and surgical results from a single-center consecutive series. J Craniomaxillofac Surg 2021; 50:156-162. [PMID: 34857442 DOI: 10.1016/j.jcms.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 09/26/2021] [Accepted: 11/10/2021] [Indexed: 10/19/2022] Open
Abstract
The purposes of this study were to describe the endoscopic-assisted orbital exenteration surgical techniques, to report preliminary outcomes and to discuss advantages, indications and limitations of this approach. All patients who underwent endoscopic-assisted orbital exenteration at a single tertiary-care center were retrospectively reviewed. A concomitant reconstruction was performed in all cases. The extent of surgical resection was tailored to the size and location of tumor and was classified into four subtypes. A total of 40 patients were included in this series. Orbital exenteration type 1 was performed in 7 cases, type 2 in 11 cases, type 3 in 19 cases, and type 4 in 3 cases. The reconstruction was performed with a pedicled temporal flap in 5 patients and with a free vascularized flap in 34 cases. A radical resection of disease was obtained in 32 cases. After a mean follow-up of 36 months, 14 patients died of disease, one patient died of other causes, 7 are alive with disease, and 18 patients are currently alive without evidence of disease. The preliminary data emerging from this case-series support the feasibility and safety of endoscopic-assisted orbital exenteration.
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Affiliation(s)
- Mario Turri-Zanoni
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Alberto Daniele Arosio
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.
| | - Paolo Battaglia
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Mario Cherubino
- Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Sergio Balbi
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Stefano Margherini
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Davide Locatelli
- Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Luigi Valdatta
- Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Paolo Castelnuovo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy; Head and Neck Surgery & Forensic Dissection Research Center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
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