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Feng S, Han S, Sun X, Li Y, Zhang Y, Li F, Wu Y, Xiao Y, Bai Y, Liang G. Endoscopic retrosigmoid trans-petrosal fissure approach for vestibular schwannomas: case series. Neurosurg Rev 2024; 47:548. [PMID: 39235642 DOI: 10.1007/s10143-024-02768-4] [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: 06/28/2024] [Revised: 08/07/2024] [Accepted: 08/25/2024] [Indexed: 09/06/2024]
Abstract
The management of vestibular schwannoma (VS) remains one of the most formidable challenges in neurosurgery owing to the eloquent nature of surrounding anatomy. Although endoscopy-assisted microsurgery has recently gained momentum in cerebellopontine angle region surgery, the feasibility of pure endoscopic technique has been rarely reported. Here we present the operative technique and preliminary outcomes of fully endoscopic retrosigmoid trans-petrosal fissure approach (ER-TPFA) for VS surgery. Clinical data of 36 consecutive cases of VS treated with the ER-TPFA from March 2021 to March 2023 were analyzed. The patients were placed in a modified lateral park-bench position, with the Dandy incision and suboccipital craniotomy performed. With the endoscopic holder, endoscopic procedures were performed using standard two-hand microsurgical techniques by one surgeon. Arachnoidal dissection of the petrosal fissure was performed for identifying the brainstem end of facial nerve and separating the tumor from the cerebellum, without brain retraction seen in traditional microsurgical technique. The tumors had an averaged size of 3.0 cm in diameter. According to the Hannover classification, nearly all the tumors were grade III-IV (97.3%). Using ER-TPFA, 33 patients (91.7%) achieved gross total resection. Anatomic preservation of the facial nerve was achieved in 35 cases, with 33 patients (91.7%) retaining a House-Brackmann score of 1-2 postoperatively. Four out of ten patients still had serviceable hearing 6 months after operation. Postoperatively, there was no post-craniotomy hematoma, cerebellar edema, and new-onset cerebellar ataxia. With a better visualization of the cerebellopontine angle region, ER-TPFA may help preserve facial nerve function and maintain high gross total resection rate while minimizing complications. We believe this retractorless technique can be a safe and effective alternative for the management of VS with satisfactory clinical results.
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Affiliation(s)
- Sizhe Feng
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Song Han
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Xiaoyu Sun
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Yuanyuan Li
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Yin Zhang
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Fei Li
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Yue Wu
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Yuanyang Xiao
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China
| | - Yang Bai
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China.
| | - Guobiao Liang
- Department of Neurosurgery, General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenhe District, Shenyang, 110015, Liaoning, China.
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Abdelghani N, Barut C, Ogut E. The investigation of cranial fossae in the intracranial cavity of fixed cadaveric skull bases: associations with sex, laterality, and clinical significance. Surg Radiol Anat 2024; 46:1305-1329. [PMID: 38858315 DOI: 10.1007/s00276-024-03408-8] [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: 03/17/2024] [Accepted: 06/03/2024] [Indexed: 06/12/2024]
Abstract
PURPOSE Our study aims to investigate three parts of the intracranial cavity, their distances to essential anatomical landmarks, and the correlations between these distances with sex, laterality, and surgical significance. METHODS The cranial nerve foraminae and essential surgical landmarks of each fossa were investigated bilaterally in 30 adult formalin-fixed cadaveric heads. Measurements, including lengths, depths, diameters, and horizontal distances to each other, to the midline of the skull, and to the outer lateral margin of the skull, were recorded on both sides. RESULTS The optic canal (OC) depth, internal auditory meatus (IAM) width, CNVII and CNIX diameters, and accessory hypoglossal canal (HC) distance were significantly greater on the left side (p < 0.05). CNVI length, CNV diameter, CNXI length, and the distances of the HC and accessory HC from the skull were significantly greater on the right side (p < 0.05). In males, correlations were found between the length of the left CNVIII and the right IAM diameter (r = 0.864, p = 0.001), right CNVIII length (r = 0.709, p = 0.022), right accessory HC length (r = 0.847, p = 0.016), and right-sided skull distance (r = 0.829, p = 0.042). In females, correlations were noted between IAM depth and length, right IAM location relative to the skull, left CNIX and CNX lengths, left CNXII length, left accessory HC location relative to the skull, and accessory HC length. CONCLUSIONS The findings of the current study indicate inherent asymmetry, sexual dimorphism, and variability in certain cranial nerves among cadaveric heads, which could have implications for surgical procedures, neuroanatomical studies, and clinical assessments. The study revealed side disparities and correlations within cranial fossa formations and essential surgical landmarks in both genders.
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Affiliation(s)
- Noor Abdelghani
- Department of Neuroscience, Institute of Graduate Studies, Bahçeşehir University, Istanbul, Türkiye
| | - Cagatay Barut
- Department of Anatomy, School of Medicine, Istanbul Medeniyet University, Istanbul, Türkiye
| | - Eren Ogut
- Department of Anatomy, School of Medicine, Istanbul Medeniyet University, Istanbul, Türkiye.
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Alexander AY, Agosti E, Leonel LCPC, Lanzino G, Peris-Celda M. Comparison Between the Supracerebellar Infratentorial and Precuneal Interhemispheric, Transtentorial Approaches to the Cerebellomesencephalic Fissure: An Anatomoradiological Study and Illustrative Cases. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00658. [PMID: 36972426 DOI: 10.1227/ons.0000000000000684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/17/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND The dorsal brainstem and cerebellomesencephalic fissure are challenging surgical targets. To afford a preferentially craniocaudal trajectory to this region, the precuneal interhemispheric transtentorial approach (PCIT) has been proposed. OBJECTIVE To didactically describe and compare exposures and anatomic indications of the supracerebellar infratentorial approach (SCIT) and PCIT to the cerebellomesencephalic fissure. METHODS Nine formalin-fixed, latex-injected cadaveric head specimens were used to perform a midline SCIT and bilateral PCITs and measure the distance of each approach. Twenty-four formalin-fixed specimens were used to measure the distance from the most posterior cortical bridging vein entering the superior sagittal sinus to the calcarine sulcus and the torcula. Fifty-one magnetic resonance images were reviewed to calculate the angle of each approach. Three illustrative surgical cases were described. RESULTS Mean distances from the brain or cerebellar surface to the operative target of the PCIT and SCIT were 7.1 cm (range: 5-7.7 cm) and 5.5 cm (range: 3.8-6.2 cm), respectively. The SCIT provided direct access to structures of the quadrigeminal cistern bilaterally. The PCIT provided access from the ipsilateral inferior colliculus to the ipsilateral infratrochlear zone. The PCIT's benefit was the direct access it provided to the cerebellomesencephalic fissure because of its superior to inferior trajectory. CONCLUSION The PCIT is indicated for unilateral lesions of the cerebellomesencephalic fissure and dorsal brainstem that harbor a craniocaudal long axis and do not have a superior extension beyond the superior colliculi. The SCIT is beneficial for lesions that extend bilaterally, have an anteroposterior long axis, or involve the Galenic complex.
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Affiliation(s)
- A Yohan Alexander
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - Edoardo Agosti
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luciano C P C Leonel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota, USA
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Kuzucu P, Türkmen T, Demirtaş OK, Güngör A, Yaman ME, Aykol Ş. Suprafloccular transhorizontal fissure approach to the cerebellopontine angle: an anatomical study with case series. Neurosurg Rev 2023; 46:62. [PMID: 36856827 DOI: 10.1007/s10143-023-01961-1] [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: 12/19/2022] [Revised: 01/30/2023] [Accepted: 01/30/2023] [Indexed: 03/02/2023]
Abstract
The suprafloccular transhorizontal fissure approach is a modified variant of the classical retrosigmoid approach option to be chosen for cerebellopontine angle lesions. In this study, we aimed to demonstrate a previously described but not widely used method, the suprafloccular transhorizontal fissure approach with anatomical dissection on the cadaver, accompanied by a case presentation with the largest clinical series in the literature. Klingler's protocol was used to prepare 8 silicone injected and 8 non-silicone injected human hemispheres. A total of 210 patients who underwent surgery in the cerebellopontine angle between 2019 and 2022 were evaluated in our clinic. Of these, the suprafloccular transhorizontal fissure approach was applied in 33 patient, and it was successful in 26 patient, but this approach could not be achieved in 7 patients. The transhorizontal fissure is a fissure in the cerebellum located between the superior semilunar lobule and the inferior semilunar lobule. In the 26 patients we operated with the suprafloccular transhorizontal fissure approach, there was no need for retraction and no complications developed. However, in 7 patients, this fissure could not be dissected due to adhesions. Suprafloccular approach is an alternative to the classical retrosigmoid approach in tumours smaller than 2 cm, medially localised with little cerebellar oedema and neurovascular compression syndrome. Because in this approach, no cerebellum retraction is required, vascular structures are better preserved and the surgical time is shortened. This approach can be applied in smaller tumours than 2 cm when the sulcal anatomy is appropriate.
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Affiliation(s)
- Pelin Kuzucu
- Department of Neurosurgery, Faculty of Medicine, Gazi University, Ankara, Türkiye
| | - Tolga Türkmen
- Department of Neurosurgery, Faculty of Medicine, Gazi University, Ankara, Türkiye
| | - Oğuz Kağan Demirtaş
- Department of Neurosurgery, Sincan Dr. Nafiz Körez State Hospital, Ankara, Türkiye
| | - Abuzer Güngör
- Department of Neurosurgery, Faculty of Medicine, Yeditepe University, İstanbul, Türkiye.,Department of Neurosurgery, Bakırköy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, İstanbul, Türkiye
| | - Mesut Emre Yaman
- Department of Neurosurgery, Faculty of Medicine, Gazi University, Ankara, Türkiye.
| | - Şükrü Aykol
- Department of Neurosurgery, Faculty of Medicine, Gazi University, Ankara, Türkiye
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Tamura R, Katayama M, Kuranari Y, Horiguchi T. Suboccipital trans-horizontal fissure approach for cerebellar hemorrhage with rupture into the upper fourth and third ventricles: the first clinical experience. Illustrative cases. JOURNAL OF NEUROSURGERY: CASE LESSONS 2022; 3:CASE21647. [PMID: 36130551 PMCID: PMC9379755 DOI: 10.3171/case21647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/03/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The authors’ previous cadaveric study reported a new surgical approach that can expose the deep cerebellar hemisphere, cerebellopontine angle, and upper fourth ventricle through dissection of the horizontal fissure of the suboccipital cerebellar hemisphere. Here, the authors present their experience with the first clinical use of the suboccipital trans-horizontal fissure (SOTHF) approach requiring access to the third and upper fourth ventricle lesions, a challenging compartment to access by traditional approaches. OBSERVATIONS In cases 1 and 2, computed tomography demonstrated large hematomas in the left cerebellar hemisphere with extension into the third ventricle and/or the upper fourth ventricle, resulting in obstructive hydrocephalus. Large hematomas in both the cerebellar hemisphere and the upper fourth ventricle were successfully removed via an SOTHF approach alone without external ventricular drainage. Furthermore, the hematoma in the third ventricle was removed through the aqueduct in case 2. Access to the upper fourth ventricle and the third ventricle were intraoperatively verified using a neuronavigation system. The patients immediately regained consciousness, and the result of cerebellar function testing was almost normal after the operation. LESSONS An SOTHF approach can achieve the removal of cerebellar and intraventricular hematomas simultaneously, is a faster and potentially safer method than others, and subsequently allows rapid clinical improvement.
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Affiliation(s)
- Ryota Tamura
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan; and
- Department of Neurosurgery, Kawasaki Municipal Hospital, Kanagawa, Japan
| | - Makoto Katayama
- Department of Neurosurgery, Kawasaki Municipal Hospital, Kanagawa, Japan
| | - Yuki Kuranari
- Department of Neurosurgery, Kawasaki Municipal Hospital, Kanagawa, Japan
| | - Takashi Horiguchi
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan; and
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