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Sun L, Su X, Ma Y, Ye M, Hong T, Zhang P, Zhang H. Microsurgical treatment for superior petrosal sinus dural arteriovenous fistulas. Neurosurg Rev 2024; 47:507. [PMID: 39207563 DOI: 10.1007/s10143-024-02743-z] [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: 04/30/2024] [Revised: 06/21/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
Superior petrosal sinus (SPS) dural arteriovenous fistulas (DAVFs) are a commonly encountered type of tentorial DAVF that occasionally requires microsurgical intervention. This study aims to analyze the tributaries of the superior petrosal vein (SPV) observed intraoperatively, their association with clinical symptoms, and venous drainage patterns. This retrospective study reviewed 34 consecutive patients with SPS DAVFs who underwent microsurgical treatment at a single institution between 2014 and 2022. The cohort had a mean age of 52.8 ± 11.8 years, with 85.3% (29/34) being male. Predominant symptoms included venous hypertensive myelopathy (VHM) (55.9%) and intraparenchymal or subarachnoid hemorrhage (23.5%). Standard retrosigmoid approach was used to ligate 94.1% (32/34) of the lesions, resulting in immediate complete fistula occlusion for all patients. Supratentorial venous drainage patterns were associated with a higher incidence of intracranial hemorrhage and venous varix (P = 0.047). Infratentorial drainage patterns were more frequently linked with VHM-related symptoms (P<0.001). Patients presenting VHM-related symptoms showed a higher prevalence of drainage through the vein of the cerebellopontine fissure (VCPF) (P = 0.01), while those with intracranial hemorrhage symptoms exhibited a higher prevalence of pontotrigeminal vein (PTV) drainage (P = 0.033) in their DAVFs. Endovascular management of SPS DAVFs carries inherent risks. Surgical treatment via standard retrosigmoid craniotomy offers favorable clinical outcomes with high rates of cure. In cases featuring infratentorial venous drainage, the predominant arterialized tributary of the SPV was the VCPF, commonly associated with VHM-related symptoms. Conversely, in cases with supratentorial venous drainage, the predominant arterialized SPV tributary was the PTV, often associated with intracranial hemorrhage symptoms.
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Affiliation(s)
- Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Xin Su
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Peng Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
- , No. 45 Changchun Street, Xicheng District, Beijing, 10053, China.
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Iampreechakul P, Wangtanaphat K, Chuntaroj S, Khunvutthidee S, Wattanasen Y, Hangsapruek S, Lertbutsayanukul P, Siriwimonmas S. Dural arteriovenous fistula involving superior petrosal sinus with petrosal venous drainage in association with cerebral venous thrombosis: Literature review and illustrative case. World Neurosurg X 2024; 22:100300. [PMID: 38435434 PMCID: PMC10904989 DOI: 10.1016/j.wnsx.2024.100300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/28/2023] [Accepted: 02/21/2024] [Indexed: 03/05/2024] Open
Abstract
Background Dural arteriovenous fistulas (DAVFs) involving superior petrosal sinus (SPS) and superior petrosal vein (SPV) are extremely rare. The pathogenesis of these fistulas remains unclear. We are illustrating 2 cases of DAVFs involving the superior petrosal sinus and veins associated with venous sinus thrombosis with a literature review. Methods We reviewed the literature using the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines focusing on DAVFs involving the SPS and/or SPV. Additionally, we searched for additional articles through the reference lists of the included studies. Results Our review yielded 20 articles from 1997 until 2022 involving 33 patients with 34 fistulas, including our 2 patients. The mean age was 55.1 ± 12.9 years (range 25-85), 54.5% were males (n = 18). The patients presented with hemorrhage in 36.4% (n = 12), and progressive myelopathy in 30.3% (n = 10). Most fistulas often had arterial supply from MMA, MHT, and/or OA. The fistulas had infratentorial drainage in 64.71% (n = 22), supratentorial drainage in 23.53% (n = 8), and both supra and infratentorial drainage in 11.76% (n = 4). In 27.3% (n = 9), cerebral venous thrombosis was mentioned or identified. Endovascular treatment was performed in 47.1% of cases (n = 16), surgery in 29.4% (n = 10), and combination of treatments in 23.5% (n = 8). A total of 30.3% (n = 10) of cases had incomplete recovery or poor result. Conclusion DAVFs involving the SPS and/or SPV are associated with aggressive natural history, requiring early diagnosis and prompt treatment, leading to good prognosis. These fistulas may be acquired in origin, probably secondary to cerebral venous thrombosis.
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Affiliation(s)
| | | | - Songpol Chuntaroj
- Department of Neuroradiology, Neurological Institute of Thailand, Bangkok, Thailand
| | | | - Yodkhwan Wattanasen
- Department of Neuroradiology, Neurological Institute of Thailand, Bangkok, Thailand
| | - Sunisa Hangsapruek
- Department of Neuroradiology, Neurological Institute of Thailand, Bangkok, Thailand
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3
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Rusu MC, Lazăr M, Vrapciu AD. Ring-shaped Dandy's superior petrosal vein. Surg Radiol Anat 2023; 45:1563-1565. [PMID: 37812287 DOI: 10.1007/s00276-023-03248-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: 07/29/2023] [Accepted: 09/25/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Dandy's superior petrosal vein (SPV) anatomy is highly relevant for neurosurgeons. The SPV drains into the superior petrosal sinus (SPS), closely related to the trigeminal and internal auditory pores. METHOD The archived enhanced MRI files of a male patient were studied. RESULTS An infratentorial ring-shaped (RS) SPV was found on the petrosal surface of the right cerebellar hemisphere. It was inserted in the SPS above the internal auditory pore, postero-lateral to the trigeminal pore. The anterior arm of that venous ring received a delicate supratrigeminal plexus of veins from the pontine surface and continued as a single venous trunk on the cerebellar surface. CONCLUSION Such previously unreported RS-SPV is of utmost importance to be identified before subtemporal transtentorial and retrosigmoid approaches for different neurosurgical reasons.
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Affiliation(s)
- Mugurel Constantin Rusu
- Division of Anatomy, Department 1, Faculty of Dentistry, "Carol Davila" University of Medicine and Pharmacy, 8 Eroilor Sanitari Blvd., 050474, Bucharest, Romania.
| | - Mihai Lazăr
- Division of Physiopathology II, Department 2, Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, 050474, Bucharest, Romania
| | - Alexandra Diana Vrapciu
- Division of Anatomy, Faculty of Stomatology, "Carol Davila" University of Medicine and Pharmacy, 050474, Bucharest, Romania
- University Emergency Hospital Bucharest, Bucharest, Romania
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Basamh M, Sinning N, Ajabnoor W, Illies T, Kehler U. Preoperative assessment of the individual anatomy of the superior petrosal vein complex using balanced fast field echo magnetic resonance imaging. Surg Radiol Anat 2023; 45:1273-1285. [PMID: 37548655 DOI: 10.1007/s00276-023-03220-w] [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: 10/02/2022] [Accepted: 07/24/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Here, we sought to examine the validity and reproducibility of balanced fast field echo (bFFE) for assessing superior petrosal vein (SPV) complex (SPVC) anatomy. METHODS Preoperative bFFE or equivalent scans and operative videos were studied and directly compared with regard to the individual anatomical features of SPVCs and their relation to the operative field. The anatomical details of the bFFE findings of the non-operated side (group 2) of all 50 patients were then reviewed, including the presence of petrosal-galenic anastomosis, and finally compared to the operated SPVCs (group 1). RESULTS A complete correlation between bFFE and intraoperative findings was observed in 62% of cases and had a significant correlation with 3 Tesla magnet strength and higher pixel bandwidth (rbis = - 0.47; p = 0.005). The sensitivity and specificity of bFFE magnetic resonance imaging were 93.7 and 95.2%, respectively, for detecting an SPV disturbing the operative field, and 97.3% and 95% for a disturbing tributary, respectively. Each group had 50 SPVCs, with a total of 70 and 64 SPVs, 10 and 11 general SPVC configurations, as well as 29 and 28 different individual anatomical variations in groups 1 and 2, respectively. Both groups had 1-3 SPVs with a similar distribution of frequencies [Chi-square (4) = 27.56; p = 0.0145 (Fisher's exact test)]. The similarity of the general configurations was not statistically significant. The same four predominant configurations constituted 80% of the SPVCs in each group. The vein of the cerebellopontine fissure was most frequently found in 86% and 88% of cases, and a petrosal-galenic anastomosis was seen in 38% and 40% of groups 1 and 2, respectively. CONCLUSIONS Individual SPVC variations are extensive. Good quality bFFE or equivalents are feasible for preoperative SPVC assessments. However, methods improving vascular visualization are recommended.
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Affiliation(s)
- Mohammed Basamh
- Division of Neurosurgery, King Abdul-Aziz University Hospital, P. O. Box 80125, 21589, Jeddah, Saudi Arabia.
| | - Nico Sinning
- Department of Neurosurgery, Asklepios Klinik Altona, Hamburg, Germany
| | - Waleed Ajabnoor
- Department of Radiology, King Abdul-Aziz University Hospital, Jeddah, Saudi Arabia
| | - Till Illies
- Department of Neuroradiology, Asklepios Klinik Altona, Hamburg, Germany
| | - Uwe Kehler
- Department of Neurosurgery, Asklepios Klinik Altona, Hamburg, Germany
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Zheng Y. Rational sacrifice of the superior petrosal vein. J Clin Neurosci 2023; 115:136-137. [PMID: 37562107 DOI: 10.1016/j.jocn.2023.08.004] [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: 06/08/2023] [Revised: 07/14/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023]
Abstract
During surgeries of the posterior cranial fossa, sacrificing the superior petrosal vein (SPV) can enhance visualization of the operative field but may also lead to postoperative venous infarction with potentially fatal consequences. We previously proposed that the safety of SPV sacrifice depends on whether there are collaterals that can take on the venous flow of the SPV after its sacrifice. Here, we propose several practical strategies that may be able to evaluate the presence of collaterals to the SPV, so that the safety of SPV sacrifice can be assessed.
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Affiliation(s)
- Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
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Yüncü ME, Karadag A, Polat S, Camlar M, Bilgin B, Quiñones-Hinojosa A, Middlebrooks EH, Özer F, Tanriover N. Comparison of the Retrosigmoid Suprameatal and Anterior Subtemporal Transpetrosal Approaches After Full Exposure of the Internal Acoustic Meatus. Oper Neurosurg (Hagerstown) 2023; 25:e126-e134. [PMID: 37255294 DOI: 10.1227/ons.0000000000000752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/14/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Surgical approaches to the ventral brainstem and petroclival regions are complex, and standard retrosigmoid and subtemporal approaches are often inadequate. Retrosigmoid suprameatal tubercle (RSMTA) and anterior subtemporal transpetrosal (ASTA) approaches may provide extended surgical exposure with less brain retraction. The objective of this study was to evaluate advantages and disadvantages of RSMTA vs ASTA, and illustrate the surgical corridors and 3-dimensional microsurgical anatomy of the related structures. METHODS Four silicone-injected adult cadaver heads (8 sides) were dissected to evaluate the accessibility of lesions located at the petrous apex, ventral brainstem, and pontomedullary region using ASTA and RSTMA. RESULTS Both ASTA and RSMTA provide access from the petrous apex to the ventral lower pons and pontomedullary junction. A greater extent of safely resected bone was found in ASTA vs RSMTA. ASTA provides a larger surgical view to the ventrolateral midpons, peritrigeminal region, superior neurovascular complex, pontomesencephalic junction, and posterior cavernous sinus. Meanwhile, through cranial nerve V mobilization, RSMTA provides a larger surgical view to the lower half part of the pons, ventrolateral part of the pontomedullary junction, and middle and lower neurovascular structures. CONCLUSION The choice of surgical approach is determined by considering the area where the lesion originates, lesion size, the anatomic structures to which it extends, and evaluation of the area that can be surgically exposed. Our study highlights the differences between these approaches and important surgical anatomic considerations.
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Affiliation(s)
- Mustafa Eren Yüncü
- Department of Neurosurgery, Tepecik Research and Training Hospital, Health Science University, Izmir, Turkey
- Microsurgical Neuroanatomy Laboratory, Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Ali Karadag
- Department of Neurosurgery, Tepecik Research and Training Hospital, Health Science University, Izmir, Turkey
| | - Sarper Polat
- Microsurgical Neuroanatomy Laboratory, Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Mahmut Camlar
- Department of Neurosurgery, Tepecik Research and Training Hospital, Health Science University, Izmir, Turkey
| | - Berra Bilgin
- Microsurgical Neuroanatomy Laboratory, Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
- Department of Neurosurgery, Tokat State Hospital, Tokat, Turkey
| | | | - Erik H Middlebrooks
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Fusun Özer
- Department of Neurosurgery, Tepecik Research and Training Hospital, Health Science University, Izmir, Turkey
| | - Necmettin Tanriover
- Microsurgical Neuroanatomy Laboratory, Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
- Department of Neurosurgery, Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Istanbul, Turkey
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Sattari SA, Shahbandi A, Xu R, Hung A, Feghali J, Yang W, Lee RP, Bettegowda C, Huang J. Sacrifice or preserve the superior petrosal vein in microvascular decompression surgery: a systematic review and meta-analysis. J Neurosurg 2023; 138:390-398. [PMID: 35901727 DOI: 10.3171/2022.5.jns22143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE In microvascular decompression (MVD) surgery through the retrosigmoid approach, the surgeon may have to sacrifice the superior petrosal vein (SPV). However, this is a controversial maneuver. To date, high-level evidence comparing the operative outcomes of patients who underwent MVD with and without SPV sacrifice is lacking. Therefore, this study sought to bridge this gap. METHODS The authors searched the Medline and PubMed databases with appropriate Medical Subject Heading (MeSH) terms and keywords. The primary outcome was vascular-related complications; secondary outcomes were new neurological deficit, cerebrospinal fluid (CSF) leak, and neuralgia relief. The pooled proportions of outcomes and OR (95% CI) for categorical data were calculated by using the logit transformation and Mantel-Haenszel methods, respectively. RESULTS Six studies yielding 1143 patients were included, of which 618 patients had their SPV sacrificed. The pooled proportion (95% CI) values were 3.82 (0.87-15.17) for vascular-related complications, 3.64 (1.0-12.42) for new neurological deficits, 2.85 (1.21-6.58) for CSF leaks, and 88.90 (84.90-91.94) for neuralgia relief. The meta-analysis concluded that, whether the surgeon sacrificed or preserved the SPV, the odds were similar for vascular-related complications (2.5% vs 1.5%, OR [95% CI] 1.01 [0.33-3.09], p = 0.99), new neurological deficits (1.2% vs 2.8%, OR [95% CI] 0.55 [0.18-1.66], p = 0.29), CSF leak (3.1% vs 2.1%, OR [95% CI] 1.16 [0.46-2.94], p = 0.75), and neuralgia relief (86.6% vs 87%, OR [95% CI] 0.96 [0.62-1.49], p = 0.84). CONCLUSIONS SPV sacrifice is as safe as SPV preservation. The authors recommend intentional SPV sacrifice when gentle retraction fails to enhance surgical field visualization and if the surgeon encounters SPV-related neurovascular conflict and/or anticipates impeding SPV-related bleeding.
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Affiliation(s)
- Shahab Aldin Sattari
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Ataollah Shahbandi
- 2Tehran School of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Risheng Xu
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Alice Hung
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - James Feghali
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Wuyang Yang
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Ryan P Lee
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Chetan Bettegowda
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Judy Huang
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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Yan Y, Xu T, Zhao Y, Mei Q, Jiang L, Hou L. Exposure region of the Kawase approach and its correlation with skull base anatomy: An evaluation with digital models. Front Surg 2023; 9:1047949. [PMID: 36684198 PMCID: PMC9852744 DOI: 10.3389/fsurg.2022.1047949] [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: 09/19/2022] [Accepted: 11/21/2022] [Indexed: 01/09/2023] Open
Abstract
The Kawase approach is one of the most used trajectories in skull base surgery. The exposure range of the approach and its correlation with skull base anatomy still demand more exploration. With the help of digital rebuilding, analysis, and measurement, we evaluated the exposure range of the Kawase and extended Kawase approaches and analyzed the correlation between the exposure range and the variants of the petrosal and clival anatomy. The finding of the study demonstrated that compared to the sub-temporal approach, the Kawase approach and the extended Kawase approach significantly added the exposure range in the upper, middle, and partial inferior regions of the clivus. The gains in the exposure volume and area are more when the manipulation angle is less than 135°.
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Affiliation(s)
- Yong Yan
- Correspondence: Yong Yan Lijun Hou
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Tayebi Meybodi A, Mignucci-Jiménez G, Lawton MT, Liu JK, Preul MC, Sun H. Comprehensive microsurgical anatomy of the middle cranial fossa: Part II-neurovascular anatomy. Front Surg 2023; 10:1132784. [PMID: 37035563 PMCID: PMC10080008 DOI: 10.3389/fsurg.2023.1132784] [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: 12/27/2022] [Accepted: 02/13/2023] [Indexed: 04/11/2023] Open
Abstract
In order to master the surgical approaches to the middle cranial fossa, the surgeon needs to understand the relevant bony anatomy. However, she/he also needs to have a clear and sound understanding of the neural and vascular anatomy because, oftentimes, the osseous anatomy (except for the optic apparatus) should be removed to expose and protect the neurovascular anatomy. This is the second of a two-part article discussing the neurovascular anatomy of the middle cranial fossa. A brief discussion of the surgical approaches follows.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, United States
- Correspondence: Ali Tayebi Meybodi
| | - Giancarlo Mignucci-Jiménez
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - James K. Liu
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, United States
- Departments of Neurosurgery and Otolaryngology, Robert Wood Johnson Barnabas Health, Newark, NJ, United States
| | - 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, AZ, United States
| | - Hai Sun
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, United States
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
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10
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Reddy TK, Olewnik Ł, Iwanaga J, Dumont AS, Tubbs RS. Cadaveric findings of a duplicated superior petrosal sinus. Anat Cell Biol 2022; 55:384-389. [PMID: 36168781 PMCID: PMC9519770 DOI: 10.5115/acb.22.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/10/2022] [Accepted: 03/29/2022] [Indexed: 11/27/2022] Open
Abstract
Knowledge of the intracranial dural venous sinuses and their variations is important in the diagnosis and management of many cranial pathologies. We report a unique duplication of the right-sided superior petrosal sinus identified during routine dissection of the skull base.. Lateral to this sinus, a separate and more curvilinear superior petrosal sinus left the normally positioned superior petrosal sinus and traveled posteriorly near the foramen spinosum and then turned medially to drain into the normally positioned superior petrosal sinus. Anteriorly, the two sinuses joined together and drained into the cavernous sinus. Posteriorly, the laterally positioned sinus drained into the normally positioned sinus which then traveled in normal fashion along the petrous ridge to end in the transverse sinus. To our knowledge, such a duplication has not been previously reported in the extant medical literature.
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Affiliation(s)
- Tina K Reddy
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - Łukasz Olewnik
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Lodz, Poland
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies.,Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, LA, USA.,Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.,University of Queensland, Brisbane, Australia
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11
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Rayan T, Helal A, Graffeo CS, Perry A, Carlstrom LP, Driscoll CLW, Link MJ. Cerebrovascular Complications of Vestibular Schwannoma Surgery. Skull Base Surg 2022; 83:e443-e448. [DOI: 10.1055/s-0041-1730895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
Abstract
Objective Cerebrovascular complications (CVC) are rare consequences of vestibular schwannoma (VS) surgery. Our objective was to assess incidences of findings suggestive of postoperative CVC in a large single surgeon cohort, as well as potential risk factors, and implications.
Study Design A cohort of 591 patients was retrospectively reviewed. Postoperative magnetic resonance images were screened for findings suggestive of stroke, T2 hyperintensity in the cerebellopontine angle structures or new encephalomalacia. Clinical records were queried for findings consistent with postoperative CVC.
Results In total, 61 patients had radiographic findings consistent with possible postoperative CVC (10%); of them, eight had documented intraoperative vascular injury (1.4%), and four had postoperative clinical exam changes indicative of CVC (0.7%). Clinically manifest intraoperative vascular injuries occurred in four patients and involved the petrosal venous complex (n = 3, 5%) or anterior inferior cerebellar artery (n = 1, 2%); clinical deficits included hemiparesis (n = 1, 2%), facial anesthesia (n = 2, 4%), dysphagia (n = 2, 2%), and unfavorable facial nerve function in two (50%). Three out of four patients in this group required out-of-home placement (75%). Clinical CVCs (n = 4) were not significantly associated with tumor size, tumor cyst, gross total resection, or length of stay. Patients with clinical CVC were significantly more likely to require posthospitalization rehabilitation (19 vs. 75%, p = 0.02; 14 vs. 100%, p = 0.0002).
Conclusion Although radiographic findings suggestive of CVC were unexpectedly common in this cohort, intraoperative vascular injury and postoperative clinical CVC were exceedingly rare. The association between unfavorable facial nerve outcome and clinical CVC is likely a marker for more difficult operations, predisposing to higher risk of complications.
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Affiliation(s)
- Tarek Rayan
- Department of Neurosurgery, Alexandria University, Alexandria, Egypt
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Ahmed Helal
- Department of Neurosurgery, Alexandria University, Alexandria, Egypt
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Lucas P. Carlstrom
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Colin L. W. Driscoll
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Departments of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael J. Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Departments of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
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12
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Kleijwegt M, Koot R, van der Mey AG, Hensen E, Malessy M. The combined TL-RS approach: Advantages and disadvantages of working 360 degrees around the sigmoid sinus. J Neurol Surg B Skull Base 2022; 84:288-295. [PMID: 37180867 PMCID: PMC10171928 DOI: 10.1055/a-1793-7925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/06/2022] [Indexed: 10/18/2022] Open
Abstract
Abstract
Objective: To highlight the advantages and disadvantages of the combined translabyrinthine (TL) and classic retrosigmoid (RS) approach.
Design: Retrospective chart review.
Setting: National Tertiary Referral Center for skull base pathology.
Participants: Twenty-two patients with very large cerebellopontine angle tumors were resected using the combined TL-RS approach.
Main outcome measures: Preoperative patient characteristics, including age, sex, and hearing loss. Tumor characteristics, pathology, and size. Intraoperative outcome: Tumor removal. Postoperative outcomes included facial nerve function, residual tumor growth, and neurological deficits.
Results: Thirteen patients had schwannoma, eight had meningioma, and one had both. The mean age was 47 years, mean tumor size was 39 × 32 × 35 mm (anterior-posterior, medial-lateral, craniocaudal), and mean follow-up period was 80 months. Tumor control was achieved in 13 patients (59%), and nine (41%) had residual tumor growth that required additional treatment. Seventeen patients (77%) had postoperative HouseBrackmann (HB) facial nerve function grade 12, one had HB grade 3, one HB V, and three HB VI.
Conclusion: Combining TL and RS approach may be helpful in safely removing large meningiomas and schwannomas in selected cases. This valuable technique should be considered when sufficient exposure cannot be achieved with the TL or RS approach alone.
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Affiliation(s)
| | | | | | | | - Martijn Malessy
- Neurosurgery, Leids Universitair Medisch Centrum, Leiden, Netherlands
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13
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Dziedzic TA, Abhinav K, Fernandez-Miranda JC. Subtemporal Approach and Its Infratentorial Extension: Review and a Comparative Analysis of Different Techniques. J Neurol Surg B Skull Base 2022; 84:89-97. [PMID: 36743711 PMCID: PMC9897897 DOI: 10.1055/s-0041-1741566] [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: 08/17/2021] [Accepted: 12/03/2021] [Indexed: 02/07/2023] Open
Abstract
Introduction Surgical resection of lesions occupying the incisural space is challenging. In a comparative fashion, we aimed to describe the anatomy and surgical approaches to the tentorial incisura and to the rostral brainstem via the intradural subtemporal approach and its infratentorial extensions. Methods Six fresh human head specimens (12 sides) were prepared for the microscopic dissection of the tentorial incisura using the intradural subtemporal approach and its infratentorial extensions. Endoscope was used to examine the anatomy of the region inadequately exposed with the microscope. Image-guided navigation was used to confirm bony structures visualized around the petrous apex. Results Standard subtemporal approach provides surgical access to the supratentorial brainstem above the pontomesencephalic sulcus and to the lateral surface of the cerebral peduncle. The linear or triangular tentorial divisions can provide access to the infratentorial space below the pontomesencephalic sulcus. The triangular tentorial flap in comparison with the linear incision obstructs the exposure of anterior incisural space and of the prepontine cistern. Visualization of the brainstem below the trigeminal nerve can be achieved by the anterior petrosectomy. Conclusion Infratentorial extension of the intradural subtemporal approach is technically demanding due to critical neurovascular structures and a relatively narrow corridor. In-depth anatomical knowledge is essential for the selection of the appropriate operative approach and safe surgical resections of lesions.
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Affiliation(s)
| | - Kumar Abhinav
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Center for Skull Base and Pituitary Neurosurgery, Southmead Hospital, Bristol, United Kingdom
| | - Juan C. Fernandez-Miranda
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States,Address for correspondence Juan C. Fernandez-Miranda, MD Department of Neurosurgery, Stanford University School of Medicine300 Pasteur Drive, Stanford, California, CA 94305-5327United States
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14
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Haq IBI, Permana AT, Susilo RI, Wahyuhadi J. Deadly complication of sacrificing superior petrosal vein during cerebellopontine angle tumor resection: A case report and literature review. Surg Neurol Int 2021; 12:306. [PMID: 34345447 PMCID: PMC8326145 DOI: 10.25259/sni_948_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 04/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background: Tumors of the cerebellopontine angle (CPA) are challenging to resect and have been proven difficult for neurosurgeons to manage optimally. Superior petrosal vein complex (SPVC) as the main drainage system and close proximity to CPA could be an obstacle during operation. There is an incidence ranging from 55% to 84% of injury to one part of the SPVC during CPA tumor surgery. Case Description: We report a case of 65-year-old woman with CPA tumor, who complained of unilateral hearing loss, dizziness, and facial pain. During tumor resection, one part of SPV complex was injured, then cerebellar edema develops. Conclusion: This case provides an overview of surgical complication associated with venous sacrifice. This would support the agreement to preserve SPV regarding risks and improve the quality of surgical decision making.
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Affiliation(s)
- Irwan Barlian Immadoel Haq
- Department of Neurosurgery, Faculty of Medicine Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, East Java, Indonesia
| | - Andhika Tomy Permana
- Department of Neurosurgery, Faculty of Medicine Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, East Java, Indonesia
| | - Rahadian Indarto Susilo
- Department of Neurosurgery, Faculty of Medicine Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, East Java, Indonesia
| | - Joni Wahyuhadi
- Department of Neurosurgery, Faculty of Medicine Universitas Airlangga - Dr. Soetomo General Academic Hospital, Surabaya, East Java, Indonesia
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15
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Xia Y, Kim TY, Mashouf LA, Patel KK, Xu R, Casaos J, Choi J, Kim ES, Hung AL, Wu A, Garzon-Muvdi T, Bender MT, Jackson CM, Bettegowda C, Lim M. Absence of Ischemic Injury after Sacrificing the Superior Petrosal Vein during Microvascular Decompression. Oper Neurosurg (Hagerstown) 2021; 18:316-320. [PMID: 31214696 DOI: 10.1093/ons/opz163] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/25/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Sacrificing the superior petrosal vein (SPV) is controversial during a microvascular decompression (MVD). There have been multiple reports of complications including life-threatening brainstem infarction and cerebellar edema. OBJECTIVE To analyze the potential for vascular complications when the SPV is sacrificed during an MVD. METHODS Retrospective chart review was performed to identify all MVDs for trigeminal neuralgia and hemifacial spasm from 2007 to 2018 at 1 institution. Cases with ≥1 mo of follow-up were included and SPV sacrifice was noted. The primary outcome was complications related to SPV sacrifice including sinus thrombosis, cerebellar edema, and midbrain or pontine infarction. Imaging was used to confirm all potential vascular complications noted in medical records. Fisher's exact test and unpaired t-tests were used to compare between groups. RESULTS A total of 732 MVD cases were identified and 592 met inclusion criteria with an average follow-up of 11.8 ± 16.4 mo and a male-to-female ratio of 1:2.2. The SPV was sacrificed in 217 cases and retained in 375 cases. No SPV-related vascular complications were found in this study. Two unrelated cases of vascular complications were identified and both were in the nonsacrificed group. One case involved cerebellar bleeding while the other was an ipsilateral transverse sinus thrombosis that was present preoperatively. CONCLUSION In MVDs, there is no difference in the rate of vascular complications when the SPV is sacrificed compared to preserved. To best visualize a cranial nerve and optimize safe decompression, surgeons should feel free to sacrifice the SPV.
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Affiliation(s)
- Yuanxuan Xia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy Y Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Leila A Mashouf
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kisha K Patel
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joshua Casaos
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John Choi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eileen S Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alice L Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adela Wu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tomas Garzon-Muvdi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew T Bender
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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16
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Inoue T, Shitara S, Goto Y, Prasetya M, Fukushima T. Petrosal Vein Involvement in Neurovascular Conflict in Trigeminal Neuralgia: Surgical Technique and Clinical Outcomes. Oper Neurosurg (Hagerstown) 2021; 20:E264-E271. [PMID: 33377154 DOI: 10.1093/ons/opaa422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 10/09/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Contact of the main stem of the petrosal vein (PV) to the nerve root is a rare cause of trigeminal neuralgia (TGN). The implication of the PV in relation with neurovascular contact (NVC) is not fully understood. OBJECTIVE To assess the operative procedures in microvascular decompression (MVD) in patients with PV involvement in the long-term. METHODS We retrospectively reviewed 34 cases (7.0%) in 485 consecutive MVDs for TGN, whose PV main stem had contact with the trigeminal nerve root (PV-NVC). PV-NVCs were divided into 2 groups: concomitant arterial contact or no concomitant arterial contact. Surgical techniques, outcomes, complications, and recurrence were assessed. RESULTS The anatomical relationship of the PV with the trigeminal nerve root was consistent with preoperative 3-dimensional imaging in all patients. Pain relief was obtained in most patients immediately after surgery (97.1%) by separating the PV from the nerve root. Postoperative facial numbness was noted in 9 patients (26.5%). Symptomatic venous infarctions occurred in 2 patients (5.9%). Recurrence of facial pain occurred in 3 patients (8.8%) with a median 48 mo follow-up period. Re-exploration surgery revealed adhesion being the cause of recurrence. The statistical analyses showed no difference in the surgical outcomes of the 2 groups. CONCLUSION Separating the PV from the nerve root contributes to pain relief in patients with PV conflict regardless of concomitant arteries. Preserving venous flow is crucial to avoid postoperative venous insufficiency.
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Affiliation(s)
- Takuro Inoue
- Department of Neurosurgery, Koto Memorial Hospital, Hiramatsu-cho, Higashiohmi-city, Shiga-Prefecture, Japan
| | - Satoshi Shitara
- Department of Neurosurgery, Koto Memorial Hospital, Hiramatsu-cho, Higashiohmi-city, Shiga-Prefecture, Japan
| | - Yukihiro Goto
- Department of Neurosurgery, Saiseikai Shiga Hospital, Shiga, Japan
| | - Mustaqim Prasetya
- Department of Neurosurgery, National Brain Center Hospital, Jakarta, Indonesia
| | - Takanori Fukushima
- Division of Neurosurgery, Duke University Medical Center, Durham, North Carolina
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17
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Abstract
The anatomy of the petrous face of the temporal bone, also known as the petrous pyramid, should be carefully examined to understand the location of, blood supply to, and venous drainage of meningiomas in this area (42%-59% of posterior fossa meningiomas). The petrous face is located in the skull base between the sphenoid and occipital bones. It consists of a base that joins the mastoid laterally and an apex that extends anteromedially to form the foramen lacerum. The anatomy can be divided into three surfaces: anterior/superior, posterior, and inferior. The anterior/superior surface is a continuation of the posteromedial portion of the middle cranial fossa with boundaries extending from the arcuate eminence to the petrous apex. The posterior surface is a continuation of the front part of the posterior cranial fossa with the internal auditory meatus at its center. The inferior surface contains foramina that transmit important vessels and cranial nerves. The vascular anatomy of the petrous face is also described, including branches of the carotid artery and vertebrobasilar systems. It is imperative to understand potential anastomotic routes between extracranial and intracranial arteries, as well as arterial supply to cranial nerves, to facilitate preoperative transarterial embolization of meningiomas and avoid neurologic complications during surgery.
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Affiliation(s)
- Ricky Chae
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States
| | - Roberto Rodriguez Rubio
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
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18
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Hou K, Lv X, Qu L, Guo Y, Xu K, Yu J. Endovascular treatment for dural arteriovenous fistulas in the petroclival region. Int J Med Sci 2020; 17:3020-3030. [PMID: 33173422 PMCID: PMC7646121 DOI: 10.7150/ijms.47365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/07/2020] [Indexed: 02/07/2023] Open
Abstract
Petroclival region dural arteriovenous fistulas (DAVFs) are rare and difficult lesions to manage. They often have very complex anatomical structures and can be further divided into the superior petrosal sinus, petrous apex, inferior petrosal sinus, upper clival, and upper clival epidural-osseous DAVFs. Most petroclival region DAVFs should be treated due to their high Cognard grades. Currently, endovascular treatment (EVT) has become the first-line therapeutic option for petroclival region DAVFs. But not all the petroclival region DAVFs could be cured with EVT. When the arterial feeders are large or the DAVF is adjacent to the venous sinus, the success rate may be higher. In petroclival region DAVFs, if EVT can be performed successfully, satisfactory outcome can be anticipated. However, there are some inadvertent complications, which include cranial nerve palsy, subsequent sinus thrombosis, and migration embolization of the internal carotid artery and vertebral artery. Currently, a review of the EVT of petroclival region DAVFs is lacking. In this article, we performed a review of the relevant literature on this issue. In addition, some illustrative cases would be provided to elaborate these specific entities.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Xianli Lv
- Department of Neurosurgery, Tsinghua Changgung Hospital of Tsinghua University, Beijing 102218, China
| | - Lai Qu
- Department of Intensive Care Unit, The First Hospital of Jilin University, Changchun, 130021, China
| | - Yunbao Guo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
- ✉ Corresponding author: Jinlu Yu. Department of Neurosurgery, The First Hospital of Jilin University, 1 Xinmin Avenue, Changchun 130021, China. ,
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19
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Basamh M, Sinning N, Kehler U. Individual variations of the superior petrosal vein complex and their microsurgical relevance in 50 cases of trigeminal microvascular decompression. Acta Neurochir (Wien) 2020; 162:197-209. [PMID: 31768757 PMCID: PMC6942005 DOI: 10.1007/s00701-019-04109-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/14/2019] [Indexed: 11/24/2022]
Abstract
Background We investigated the understudied anatomical variations of the superior petrosal vein (SPV) complex (SPVC), which may play some role in dictating the individual complication risk following SPVC injury. Methods Microvascular decompressions of the trigeminal nerve between September 2012 and July 2016. All operations utilized an SPVC preserving technique. Preoperative balanced fast field echo (bFFE) magnetic resonance imaging, or equivalent sequences, and operative videos were studied for individual SPVC anatomical features. Results Applied imaging and operative SPVC anatomy were described for fifty patients (mean age, 67.18 years; female sex and right-sided operations, 58% each). An SPVC component was sacrificed intentionally in 6 and unintentionally in only 7 cases. Twenty-nine different individual variations were observed; 80% of SPVCs had either 2 SPVs with 3 or 1 SPV with 2, 3, or 4 direct tributaries. Most SPVCs had 1 SPV (64%) and 2 SPVs (32%). The SPV drainage point into the superior petrosal sinus was predominantly between the internal auditory meatus and Meckel cave (85.7% of cases). The vein of the cerebellopontine fissure was the most frequent direct tributary (86%), followed by the pontotrigeminal vein in 80% of SPVCs. Petrosal-galenic anastomosis was detected in at least 38% of cases. At least 1 SPV in 54% of the cases and at least 1 direct tributary in 90% disturbed the operative field. The tributaries were more commonly sacrificed. Conclusions The extensive anatomical variation of SPVC is depicted. Most SPVCs fall into 4 common general configurations and can usually be preserved. BFFE or equivalent sequences remarkably facilitated the intraoperative understanding of the individual SPVC in most cases.
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Affiliation(s)
- Mohammed Basamh
- Department of Neurosurgery, Asklepios Klinik Altona, Paul-Ehrlich Strasse 1, 22763, Hamburg, Germany.
- Division of Neurosurgery, King Abdul-Aziz University Hospital, Jeddah, Saudi Arabia.
| | - Nico Sinning
- Department of Neurosurgery, Asklepios Klinik Altona, Paul-Ehrlich Strasse 1, 22763, Hamburg, Germany
| | - Uwe Kehler
- Department of Neurosurgery, Asklepios Klinik Altona, Paul-Ehrlich Strasse 1, 22763, Hamburg, Germany
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20
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Urculo E, Elua A, Arrazola M, Torres P, Torres S, Undabeitia J. Trigeminal root massage in microsurgical treatment of trigeminal neuralgia patients without arterial compression: When, how and why. Neurocirugia (Astur) 2019; 31:53-63. [PMID: 31668629 DOI: 10.1016/j.neucir.2019.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/31/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND During the microsurgical exploration of trigeminal root in the pontocerebellar angle in patients with primary trigeminal neuralgia (TN) without an evident arterial compression, the surgeon is in an engaged situation because there are not well-established surgical strategies. The aim of this study is to describe in these cases the surgical maneuver we call "trigeminal root massage" (TRM). METHODS 52 consecutive patients with primary trigeminal neuralgia who had undergone a microsurgical suboccipital retrosigmoid exploration of trigeminal root were reviewed. Among them we found 10 patients without an evident arterial compression after a thorough microsurgical exploration. In the great majority of these 10 cases, we noticed a venous contact to the trigeminal root along this cisternal trajectory, in most cases we have had to coagulate the compressive vein/s and then cut. All underwent a simple trigeminal root massage, without interposition of any material implant. RESULTS All 10 patients experienced immediate pain disappearance and the postoperative course was uneventful except one case with a severe complication: cerebellar swelling, meningitis and hydrocephaly. The recurrence rate was 40%. Six patients achieved pain relief without specific medication with an average follow-up period of 5 years. There have been no mortalities nor any postoperative anesthesia dolorosa. CONCLUSIONS The described maneuver provides an easy and simple alternative way in cases where during a microsurgical exploration of trigeminal root, where we don't find a clear arterial compression, with similar results than other possibilities such as partial sensory rhizotomy or more complicated and time consuming surgery as "nerve combing". Nevertheless, a 40% of pain recurrence after an average follow-up of 5 years means that is a good alternative, but not a definitive technique at the moment for permanent cure of trigeminal neuralgia without arterial compression.
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Affiliation(s)
- Enrique Urculo
- Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain.
| | - Alejandro Elua
- Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain
| | - Mariano Arrazola
- Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain
| | - Patricia Torres
- Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain
| | - Sergio Torres
- Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain
| | - Jose Undabeitia
- Department of Neurosurgery, Hospital Universitario Donostia, Paseo Dr. Beguiristain S/N, San Sebastian, Spain
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21
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Narayan V, Savardekar AR, Patra DP, Mohammed N, Thakur JD, Riaz M, Nanda A. Safety profile of superior petrosal vein (the vein of Dandy) sacrifice in neurosurgical procedures: a systematic review. Neurosurg Focus 2019; 45:E3. [PMID: 29961377 DOI: 10.3171/2018.4.focus18133] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Walter E. Dandy described for the first time the anatomical course of the superior petrosal vein (SPV) and its significance during surgery for trigeminal neuralgia. The patient's safety after sacrifice of this vein is a challenging question, with conflicting views in current literature. The aim of this systematic review was to analyze the current surgical considerations regarding Dandy's vein, as well as provide a concise review of the complications after its obliteration. METHODS A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A thorough literature search was conducted on PubMed, Web of Science, and the Cochrane database; articles were selected systematically based on the PRISMA protocol and reviewed completely, and then relevant data were summarized and discussed. RESULTS A total of 35 publications pertaining to the SPV were included and reviewed. Although certain studies report almost negligible complications of SPV sectioning, there are reports demonstrating the deleterious effects of SPV obliteration when achieving adequate exposure in surgical pathologies like trigeminal neuralgia, vestibular schwannoma, and petroclival meningioma. The incidence of complications after SPV sacrifice (32/50 cases in the authors' series) is 2/32 (6.2%), and that reported in various case series varies from 0.01% to 31%. It includes hemorrhagic and nonhemorrhagic venous infarction of the cerebellum, sigmoid thrombosis, cerebellar hemorrhage, midbrain and pontine infarct, intracerebral hematoma, cerebellar and brainstem edema, acute hydrocephalus, peduncular hallucinosis, hearing loss, facial nerve palsy, coma, and even death. In many studies, the difference in incidence of complications between the SPV-sacrificed group and the SPV-preserved group was significant. CONCLUSIONS The preservation of Dandy's vein is a neurosurgical dilemma. Literature review and experiences from large series suggest that obliterating the vein of Dandy while approaching the superior cerebellopontine angle corridor may be associated with negligible complications. However, the counterview cannot be neglected in light of some series showing an up to 30% complication rate from SPV sacrifice. This review provides the insight that although the incidence of complications due to SPV obliteration is low, they can happen, and the sequelae might be worse than the natural history of the existing pathology. Therefore, SPV preservation should be attempted to optimize patient outcome.
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22
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Bender B, Hauser TK, Korn A, Klose U, Tatagiba M, Ernemann U, Ebner FH. Depiction of the Superior Petrosal Vein Complex by 3D Contrast-Enhanced MR Angiography. AJNR Am J Neuroradiol 2018; 39:2249-2255. [PMID: 30409853 DOI: 10.3174/ajnr.a5864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 09/10/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intraoperative obliteration of the superior petrosal vein complex has a relevant risk of postoperative complications. A large venous diameter and the absence of anastomoses have been previously suggested as possible risk factors. 3D contrast-enhanced MRA was evaluated for the identification of superior petrosal vein anatomy. MATERIALS AND METHODS Twenty-five patients (10 men; age, 20-77 years) with a 3D-MRA (voxel size, 0.4 × 0.4 × 0.5 mm3) at 3T, including the posterior fossa, were retrospectively identified. Image evaluation was performed independently by 2 neuroradiologists with respect to overall image quality and the presence, location, size, tributaries, and anastomotic veins of the superior petrosal vein complex. Additionally, 8 neurosurgical cases with intraoperative validation of the venous anatomy were examined. RESULTS All studies were of diagnostic image quality. Interobserver agreement was excellent for image-quality measurements (r = 0.751-0.982) and good for measured vessel size (r = 0.563-0.828). A total of 83 superior petrosal veins were identified. The distribution of drainage locations and identification of tributaries and anastomotic veins were consistent with previous anatomic studies. The results showed that 4.8% of superior petrosal veins had a diameter of >2 mm and lacked a visible anastomosis. All surgical cases showed excellent agreement between the MRA and the intraoperative observations. CONCLUSIONS 3D-MRA with high resolution is appropriate for analyzing the size, course, tributaries, and anastomoses of the superior petrosal vein. A total of 4.8% of the identified superior petrosal veins had to be classified as potential high-risk veins. The measurements correlated with the intraoperative findings.
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Affiliation(s)
- B Bender
- From the Department of Radiology (B.B., T.-K.H., A.K., U.K., U.E.), Diagnostic and Interventional Neuroradiology
| | - T-K Hauser
- From the Department of Radiology (B.B., T.-K.H., A.K., U.K., U.E.), Diagnostic and Interventional Neuroradiology
| | - A Korn
- From the Department of Radiology (B.B., T.-K.H., A.K., U.K., U.E.), Diagnostic and Interventional Neuroradiology.,Radiologie in Hof (A.K.), Hof, Germany
| | - U Klose
- From the Department of Radiology (B.B., T.-K.H., A.K., U.K., U.E.), Diagnostic and Interventional Neuroradiology
| | - M Tatagiba
- Department of Neurosurgery (M.T., F.H.E.), University Hospital Tübingen, Tübingen, Germany
| | - U Ernemann
- From the Department of Radiology (B.B., T.-K.H., A.K., U.K., U.E.), Diagnostic and Interventional Neuroradiology
| | - F H Ebner
- Radiologie in Hof (A.K.), Hof, Germany
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23
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Matsushima T, Matsushima K, Kobayashi S, Lister JR, Morcos JJ. The microneurosurgical anatomy legacy of Albert L. Rhoton Jr., MD: an analysis of transition and evolution over 50 years. J Neurosurg 2018; 129:1331-1341. [PMID: 29393756 DOI: 10.3171/2017.7.jns17517] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 07/13/2017] [Indexed: 11/06/2022]
Abstract
The authors chronologically categorized the 160 original articles written by Dr. Rhoton and his fellows to show why they selected their themes and how they carried out their projects. The authors note that as neurosurgery progresses and new techniques and approaches are developed, accurate and safe treatment will depend upon continued clarification of microsurgical anatomy.
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Affiliation(s)
- Toshio Matsushima
- 1International University of Health and Welfare
- 2Neuroscience Center, Fukuoka Sanno Hospital, Fukuoka
| | - Ken Matsushima
- 3Department of Neurosurgery, Tokyo Medical University, Tokyo
| | - Shigeaki Kobayashi
- 4Medical Research and Education Center, Aizawa Hospital, Matsumoto, Japan
| | - J Richard Lister
- 5Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville; and
| | - Jacques J Morcos
- 6Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
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24
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Blitz AM, Northcutt B, Shin J, Aygun N, Herzka DA, Theodros D, Goodwin CR, Lim M, Seeburg DP. Contrast-Enhanced CISS Imaging for Evaluation of Neurovascular Compression in Trigeminal Neuralgia: Improved Correlation with Symptoms and Prediction of Surgical Outcomes. AJNR Am J Neuroradiol 2018; 39:1724-1732. [PMID: 30139749 DOI: 10.3174/ajnr.a5743] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 06/17/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Thin-section MR imaging through the posterior fossa is frequently used for trigeminal neuralgia. Typical heavily T2-weighted imaging methods yield high anatomic detail and contrast between CSF and neurovascular structures, but poor contrast between vessels and nerves. We hypothesized that the addition of gadolinium-based contrast material to 3D-constructive interference in steady-state imaging would improve the characterization of trigeminal compression. MATERIALS AND METHODS Retrospective review of high-resolution MRIs was performed in patients without prior microvascular decompression. 3D-CISS imaging without contrast and with contrast for 81 patients with trigeminal neuralgia and 15 controls was intermixed and independently reviewed in a blinded fashion. Cisternal segments of both trigeminal nerves were assessed for the grade of neurovascular conflict, cross-sectional area, and degree of flattening. Data were correlated with symptom side and pain relief after microvascular decompression using the Fisher exact test, receiver operating curve analysis, and a paired t test. RESULTS Contrast-enhanced CISS more than doubled the prevalence of the highest grade of neurovascular conflict (14.8% versus 33.3%, P = .001) and yielded significantly lower cross-sectional area (P = 8.6 × 10-6) and greater degree of flattening (P = .02) for advanced-grade neurovascular conflict on the symptoms side compared with non-contrast-enhanced CISS. Patients with complete pain relief after microvascular decompression had significantly lower cross-sectional area on contrast-enhanced CISS compared with non-contrast-enhanced CISS on preoperative imaging (P = 2.0 × 10-7). Performance based on receiver operating curve analysis was significantly improved for contrast-enhanced CISS compared with non-contrast-enhanced CISS. CONCLUSIONS The addition of contrast material to 3D-CISS imaging improves the performance of identifying unilateral neurovascular compression for symptomatic trigeminal neuralgia and predicting outcomes after microvascular decompression.
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Affiliation(s)
- A M Blitz
- From the Departments of Radiology and Radiological Science (A.M.B., B.N., J.S., N.A., D.P.S.)
| | - B Northcutt
- From the Departments of Radiology and Radiological Science (A.M.B., B.N., J.S., N.A., D.P.S.)
| | - J Shin
- From the Departments of Radiology and Radiological Science (A.M.B., B.N., J.S., N.A., D.P.S.)
| | - N Aygun
- From the Departments of Radiology and Radiological Science (A.M.B., B.N., J.S., N.A., D.P.S.)
| | | | - D Theodros
- Neurosurgery (D.T., C.R.G., M.L.), Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - C R Goodwin
- Neurosurgery (D.T., C.R.G., M.L.), Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - M Lim
- Neurosurgery (D.T., C.R.G., M.L.), Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - D P Seeburg
- From the Departments of Radiology and Radiological Science (A.M.B., B.N., J.S., N.A., D.P.S.)
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Zhao X, Hao S, Wang M, Han C, Xing D, Wang C. Management of veins during microvascular decompression for idiopathic trigeminal neuralgia. Br J Neurosurg 2018; 32:484-488. [PMID: 29792350 DOI: 10.1080/02688697.2018.1476674] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECT To summarize our experience in treating veins during microvascular decompression (MVD) procedures for idiopathic trigeminal neuralgia (TN). METHODS A total of 210 patients who underwent single MVD for idiopathic TN were retrospectively studied. The offending vessels were summarized. The treatment choices for veins during the operation were reviewed. Postoperative long-term outcomes were determined by follow-up. RESULTS Veins accounted for 26.7% of the total 262 offending vessels. Neurovascular conflicts were caused by veins alone in 23 patients (11.2%), and they were caused by arteries and veins together in 47 patients (22.8%). The offending veins were cut (15.7%) or saved (84.3%) during the operation. Excellent long-term outcomes were acquired in 78.3% of the patients with venous type TN. CONCLUSION There are no acknowledged principles guiding the treatment of veins during MVD. Our primary treatment principle is to retain veins as often as possible.
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Affiliation(s)
- Xu Zhao
- a Department of Neurosurgery , The Second Hospital of Shandong University , Jinan , Shandong Province , China
| | - Shuai Hao
- b Department of Neurosurgery , People's Hospital of Juye County , Juye , Shandong Province , China
| | - Minqing Wang
- a Department of Neurosurgery , The Second Hospital of Shandong University , Jinan , Shandong Province , China
| | - Chao Han
- a Department of Neurosurgery , The Second Hospital of Shandong University , Jinan , Shandong Province , China
| | - Deguang Xing
- a Department of Neurosurgery , The Second Hospital of Shandong University , Jinan , Shandong Province , China
| | - Chengwei Wang
- a Department of Neurosurgery , The Second Hospital of Shandong University , Jinan , Shandong Province , China
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The Tentorial Bridge to Deep Skull Base Exposure: Anatomic Morphometric Study. World Neurosurg 2018; 114:e588-e596. [PMID: 29551719 DOI: 10.1016/j.wneu.2018.03.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/02/2018] [Accepted: 03/05/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Skull base surgeons split the tentorium to expand exposure, minimize brain retraction, and combine the supratentorial and infratentorial compartments for resection of large skull base lesions. The aim of this study was to describe stepwise techniques for splitting the tentorium to access deeply located skull base lesions and morphometrically assess gained exposure. METHODS Surgical exposures were performed through transsylvian, subtemporal, posterior transpetrosal, and combined posterior supratentorial/infratentorial-transsinus approaches. A custom software program was used to trace the surgical exposure region of interest for area analysis with the ability to accurately assess most irregular areas. Qualitative morphometric assessment was done of the gain in anatomic exposure achieved by splitting the tentorium. RESULTS In the transsylvian transtentorial approach, mean surface area increased 154.17%, from 0.14 cm2 before expansion to 0.32 cm2 after expansion. In the subtemporal transtentorial approach, mean surface area increased 137.61%, from 0.66 cm2 before expansion to 1.52 cm2 after expansion. In the posterior transpetrosal transtentorial approach, mean surface area increased 171.06%, from 1.08 cm2 before expansion to 2.81 cm2 after expansion. In the combined supratentorial/infratentorial-transsinus approach, mean surface area increased 222.03%, from 0.78 cm2 before expansion to 2.38 cm2 after expansion. CONCLUSIONS With splitting of the tentorium, a substantial area of expansion is obtained, minimizing the need for brain retraction and improving visualization of deep neurovascular structures in the skull base.
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Adachi K, Hasegawa M, Hirose Y. Evaluation of Venous Drainage Patterns for Skull Base Meningioma Surgery. Neurol Med Chir (Tokyo) 2017; 57:505-512. [PMID: 28579577 PMCID: PMC5638777 DOI: 10.2176/nmc.ra.2016-0336] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The evaluation of venous drainage patterns prior to surgery for skull base meningioma is important owing to their deep location and the vulnerability of surrounding vascular structures. In recent years, the microsurgical skull base approach has matured as a surgical technique, making it an important option for reducing complications related to skull base meningioma surgery. In addition, knowledge of the venous anatomy can prevent venous drainage route disturbance and potentially life-threatening complications. Hence, this topic review aimed to provide an overview of normal venous anatomy as it relates to the microsurgical skull base approach, discuss known changes in venous drainage routes that are associated with the progression of skull base meningioma and the selection of an appropriate operative approach with the highest likelihood of preserving venous drainage structures.
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Affiliation(s)
- Kazuhide Adachi
- Department of Neurosurgery, School of Medicine, Fujita Health University
| | - Mitsuhiro Hasegawa
- Department of Neurosurgery, School of Medicine, Fujita Health University
| | - Yuichi Hirose
- Department of Neurosurgery, School of Medicine, Fujita Health University
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Liebelt BD, Barber SM, Desai VR, Harper R, Zhang J, Parrish R, Baskin DS, Trask T, Britz GW. Superior Petrosal Vein Sacrifice During Microvascular Decompression: Perioperative Complication Rates and Comparison with Venous Preservation. World Neurosurg 2017; 104:788-794. [PMID: 28559083 DOI: 10.1016/j.wneu.2017.05.098] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 05/15/2017] [Accepted: 05/18/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate potential effect of sacrifice of the superior petrosal vein (SPV) on postoperative complications after microvascular decompression (MVD). METHODS Retrospective review of 98 consecutive patients undergoing MVD of cranial nerve V was performed. Frequency of division of the SPV during surgery was recorded, and postoperative complications and imaging were recorded and analyzed. In patients with complications, the specific anatomic variation of the superior petrosal venous complex was noted. RESULTS Of 98 patients undergoing MVD, 83 (84.7%) had sacrifice of the SPV at the time of surgery, 12 (12.2%) had the SPV preserved, and 3 (3.1%) were revision operations. Four patients (4.8%) had complications deemed to be attributable to venous insufficiency or congestion. These included sigmoid sinus thrombosis with coincident cerebellar hemorrhage, midbrain and pontine infarction, hemiparesis with midbrain and pontine edema, and facial paresis with ischemia in the middle cerebellar peduncle. None of the patients with preserved SPV were symptomatic or had imaging changes consistent with venous congestion. CONCLUSIONS Sacrifice of the SPV is often performed during MVD. This is associated with a complication rate that is significant in frequency and severity compared with preserving the vein. SPV sacrifice should be limited to cases where it is deemed absolutely necessary for successful cranial nerve decompression.
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Affiliation(s)
- Brandon D Liebelt
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, Texas, USA
| | - Sean M Barber
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, Texas, USA
| | - Viren R Desai
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, Texas, USA
| | - Richard Harper
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, Texas, USA
| | - Jonathan Zhang
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, Texas, USA
| | - Rob Parrish
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, Texas, USA
| | - David S Baskin
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, Texas, USA
| | - Todd Trask
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, Texas, USA
| | - Gavin W Britz
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, Texas, USA.
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29
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Fatal cerebellar infarction after sacrifice of the superior petrosal vein during surgery for petrosal apex meningioma. J Clin Neurosci 2016; 35:144-145. [PMID: 27816259 DOI: 10.1016/j.jocn.2016.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 10/15/2016] [Indexed: 11/23/2022]
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30
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Mortazavi MM, Cox MA, Saker E, Krishnamurthy S, Verma K, Griessenauer CJ, Loukas M, Oskouian RJ, Tubbs RS. The superior petrosal sinus: a review of anatomy, embryology, pathology, and neurosurgical relevance. Neurosurg Rev 2016; 41:713-718. [DOI: 10.1007/s10143-016-0785-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 09/12/2016] [Indexed: 11/27/2022]
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Marchand AJ, Seguin P, Malledant Y, Taleb M, Raoult H, Gauvrit JY. Revised CT angiography venous score with consideration of infratentorial circulation value for diagnosing brain death. Ann Intensive Care 2016; 6:88. [PMID: 27620878 PMCID: PMC5020015 DOI: 10.1186/s13613-016-0188-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 08/29/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Computed tomography angiography (CTA) is largely performed in European countries as an ancillary test for diagnosing brain death. However, CTA suffers from a lack of sensitivity, especially in patients who have previously undergone decompressive craniectomy. The aim of this study was to assess the performance of a revised four-point venous CTA score, including non-opacification of the infratentorial venous circulation, for diagnosing brain death. METHODS A preliminary study of 43 control patients with normal CTAs confirmed that the infratentorial superior petrosal vein (SPV) was consistently visible. Therefore, 76 patients (including ten with decompressive craniectomy) who were investigated with 83 CTAs to confirm clinical brain death were consecutively enrolled between July 2011 and July 2013 at a university centre. The image analysis consisted of recording non-opacification of the cortical segment of the middle cerebral artery and internal cerebral vein (ICV), which were used as the reference CTA score, as well as non-opacification of the SPV. The diagnostic performance of the revised four-point venous CTA score based on the non-opacification of both the ICV and SPV was assessed and compared with that of the reference CTA score. RESULTS The revised four-point venous CTA score showed a sensitivity of 95 % for confirming clinical brain death versus a sensitivity of 88 % with the reference CTA score. Non-opacification of the SPV was observed in 95 % of the patients. In the decompressive craniectomy group, the revised four-point CTA score showed a sensitivity of 100 % compared with a sensitivity of 80 % using the reference CTA score. CONCLUSION Compared with the reference CTA score, the revised four-point venous CTA score based on ICV and SPV non-opacification showed superior diagnostic performance for confirming brain death, including for patients with decompressive craniectomy.
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Affiliation(s)
- Antoine J Marchand
- Department of Radiology and Medical Imaging, University and Regional Hospital Center (CHRU) of Rennes, 2 rue Henri Le Guillou, 35000, Rennes, France.
| | - Philippe Seguin
- Service d'Anesthésie Réanimation 1, CHU Rennes, 2 rue Henri Le Guillou, 35000, Rennes, France.,Université Rennes 1, Rennes, France.,Inserm U991, Rennes, France
| | - Yannick Malledant
- Service d'Anesthésie Réanimation 1, CHU Rennes, 2 rue Henri Le Guillou, 35000, Rennes, France.,Université Rennes 1, Rennes, France.,Inserm U991, Rennes, France
| | - Marion Taleb
- Service d'Anesthésie Réanimation 1, CHU Rennes, 2 rue Henri Le Guillou, 35000, Rennes, France
| | - Hélène Raoult
- Department of Radiology and Medical Imaging, University and Regional Hospital Center (CHRU) of Rennes, 2 rue Henri Le Guillou, 35000, Rennes, France
| | - Jean Yves Gauvrit
- Department of Radiology and Medical Imaging, University and Regional Hospital Center (CHRU) of Rennes, 2 rue Henri Le Guillou, 35000, Rennes, France.,Université Rennes 1, Rennes, France
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Mizutani K, Toda M, Yoshida K. The Analysis of the Petrosal Vein to Prevent Venous Complications During the Anterior Transpetrosal Approach in the Resection of Petroclival Meningioma. World Neurosurg 2016; 93:175-82. [PMID: 27312392 DOI: 10.1016/j.wneu.2016.06.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 06/03/2016] [Accepted: 06/06/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The anterior transpetrosal approach (ATPA) has been used in the resection of petroclival meningioma (PCM) for more than 20 years. Although PCM sometimes involves the petrosal vein and its preservation has been an important issue, the precise risk of petrosal vein sacrifice and subsequent venous complications associated with the use of the ATPA in patients with PCM has not yet been elucidated. METHODS We used computed tomographic (CT) digital subtraction venography (DSV) in the retrospective analysis of the petrosal vein and its tributaries in patients with PCM before and after surgery. We also examined the incidence of postoperative venous complications in each of the patients. RESULTS The detection rate of the petrosal vein and some of its tributaries on CT-DSV in patients with PCM was significantly lower than that in controls. Preoperatively, CT-DSV detected the petrosal vein in 71.8% of patients with PCM. The detected petrosal veins were preserved after the operation in 64.3% of these patients. No venous complications involving petrosal vein were observed in any of the patients. Anastomosis between the petrosal vein and the basal vein via the pontotrigeminal vein was found to be significantly more developed in the patients with PCM compared with the controls. CONCLUSIONS Our study demonstrated that the ATPA could be performed safely on patients with PCM from the viewpoint of venous preservation. Preoperative CT-DSV is important for assessing the petrosal vein and its tributaries to facilitate a safer operation.
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Affiliation(s)
- Katsuhiro Mizutani
- Department of Neurosurgery, Keio University School of Medicine, Shinjukuku, Tokyo, Japan.
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, Shinjukuku, Tokyo, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, Shinjukuku, Tokyo, Japan
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Cheng L. Complications after obliteration of the superior petrosal vein: Are they rare or just underreported? J Clin Neurosci 2016; 31:1-3. [PMID: 27178112 DOI: 10.1016/j.jocn.2015.11.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 11/11/2015] [Accepted: 11/13/2015] [Indexed: 10/21/2022]
Abstract
Dandy first described the course of the superior petrosal vein (SPV) and its importance during surgery in 1929. Although it has been reported that this vein can be sacrificed without complication, unfavourable outcomes may occur after dividing the SPV. We review these consequences, which may include peduncular hallucinosis and hearing loss, or even hemorrhage, and discuss factors that may contribute to complications. Preservation of the SPV should be attempted whenever possible to increase the safety of surgery.
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Affiliation(s)
- Lei Cheng
- Department of Neurosurgery, the Affiliated Hospital of Qingdao University, Jiangsu Road 16, Qingdao, Shandong 266003, China.
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Wangaryattawanich P, Chavali LS, Shah KB, Gogia B, Valenzuela RF, DeMonte F, Kumar AJ, Hayman LA. Contrast-enhanced Reformatted MR Images for Preoperative Assessment of the Bridging Veins of the Skull Base. Radiographics 2016; 36:244-57. [DOI: 10.1148/rg.2016150084] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Dumot C, Sindou M. Trigeminal neuralgia due to neurovascular conflicts from venous origin: an anatomical-surgical study (consecutive series of 124 operated cases). Acta Neurochir (Wien) 2015; 157:455-66. [PMID: 25604274 DOI: 10.1007/s00701-014-2330-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 12/22/2014] [Indexed: 01/03/2023]
Abstract
BACKGROUND Veins as the source of trigeminal neuralgias (TN) lead to controversies. Only a few studies have specifically dealt with venous implication in neurovascular conflicts (NVC). The aim of this study was the anatomical-surgical description of the compressive veins found during micro-vascular decompression (MVD). METHODS Patients retained were those in whom a vein was considered compressive, alone, or in association with an artery. The study defined the type of vein involved, its situation along, the location around the root, and management. For this study, denomination of veins in relation with the root was revisited. RESULTS Of the 326 consecutive patients who underwent MVD from 2005 to 2013, 124 (38.0 %) had a venous conflict, alone in 29 (8.9 %), or in association with an artery in 95 (29.1 %). The compressive veins belonged to one of the two venous systems described: the superficial or the deep superior petrosal venous system (sSPVS or dSPVS). A vein from sSPVS was found compressive in 81 cases (59.6 %), for the major part it was the pontine affluent of the superior petrosal vein (48 cases). The conflict was situated at TREZ in 28.4 %, mid-cisternal portion in 50.6 %, and porus in 8.6 %. The dSPVS was found compressive in 55 cases (40.4 %), almost always a transverse vein at porus (51 cases). Decompression was coagulation-division of the conflicting vein in 36.8 % and simple cleavage in the other. CONCLUSIONS The study shows the frequent implication of veins in NVC as the source of TN. NVC are not only at TREZ but also at mid-cisternal portion and porus of Meckel cave.
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Affiliation(s)
- Chloé Dumot
- Department of Neurosurgery, University of Lyon 1 Hôpital Neurologique "P. Wertheimer", Lyon, France,
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36
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Matsushima K, Ribas ESC, Kiyosue H, Komune N, Miki K, Rhoton AL. Absence of the superior petrosal veins and sinus: Surgical considerations. Surg Neurol Int 2015; 6:34. [PMID: 25745589 PMCID: PMC4348801 DOI: 10.4103/2152-7806.152147] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 11/21/2014] [Indexed: 11/17/2022] Open
Abstract
Background: The superior petrosal vein, one of the most constant and largest drainage pathways in the posterior fossa, may result in complications if occluded. This study calls attention to a unique variant in which the superior petrosal veins and sinus were absent unilaterally, and the venous drainage was through the galenic and tentorial drainage groups. Methods: This study examines one venogram and another anatomic specimen in which the superior petrosal vein and sinus were absent. Results: The superior petrosal veins, described as 1–3 bridging veins, emptying into the superior petrosal sinus, are the major drainage pathways of the petrosal group of posterior fossa veins. In the cases presented, the superior petrosal vein and sinus were absent and venous drainage was through the galenic and tentorial groups, including the lateral mesencephalic or bridging vein on the tentorial cerebellar surface. Conclusions: In cases in which the superior petrosal sinus and veins are absent, care should be directed to preserving the collateral drainage through the galenic and tentorial tributaries. Although surgical strategies for intraoperative management and preservation of venous structures are still controversial, knowledge of the possible anatomical variations is considered to be essential to improve surgical outcomes.
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Affiliation(s)
- Ken Matsushima
- Department of Neurological Surgery, University of Florida, PO Box 100265, Gainesville, Florida, 32610, USA
| | | | - Hiro Kiyosue
- Department of Radiology, Oita University, Faculty of Medicine, 1-1 Idaigaoka, Hasama, Yufu City, Oita, Japan 879-5503
| | - Noritaka Komune
- Department of Neurological Surgery, University of Florida, PO Box 100265, Gainesville, Florida, 32610, USA
| | - Koichi Miki
- Department of Neurosurgery, Fukuoka University, Faculty of Medicine, 7-45-1 Nanakuma Jonan-ku, Fukuoka, Japan 814-0180
| | - Albert L Rhoton
- Department of Neurological Surgery, University of Florida, PO Box 100265, Gainesville, Florida, 32610, USA
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Dumot C, Sindou M. Trigeminal neuralgia due to neurovascular conflicts from venous origin: an anatomical-surgical study (consecutive series of 124 operated cases). Acta Neurochir (Wien) 2015. [DOI: 10.1007/s00701-014-2330-3 epub 2015 jan 22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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38
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Matsushima K, Matsushima T, Kuga Y, Kodama Y, Inoue K, Ohnishi H, Rhoton AL. Classification of the superior petrosal veins and sinus based on drainage pattern. Neurosurgery 2015; 10 Suppl 2:357-67; discussion 367. [PMID: 24561869 DOI: 10.1227/neu.0000000000000323] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The increasing number of reports of complications after sacrificing the superior petrosal veins, the largest veins in the posterior fossa, has led to a need for an increased understanding of the anatomy of these veins and the superior petrosal sinus into which they empty. OBJECTIVE To examine the anatomy of the superior petrosal veins and their size, draining area, and tributaries, as well as the anatomic variations of the superior petrosal sinus. METHOD Injected cadaveric cerebellopontine angles and 3-dimensional multifusion angiography images were examined. RESULTS The 4 groups of the superior petrosal veins based on their tributaries, course, and draining areas are the petrosal, posterior mesencephalic, anterior pontomesencephalic, and tentorial groups. The largest group was the petrosal group. Its largest tributary, the vein of the cerebellopontine fissure, was usually identifiable in the suprafloccular cistern located above the flocculus on the lateral surface of the middle cerebellar peduncle. The medial or lateral segment of the superior petrosal sinus was absent in 40% of cerebellopontine angles studied with venography. CONCLUSION The superior petrosal veins and their largest tributaries, especially the vein of the cerebellopontine fissure, should be preserved if possible. Obliteration of superior petrosal sinuses in which either the lateral or medial portion is absent may result in loss of the drainage pathway of the superior petrosal veins. Preoperative assessment of the superior petrosal sinus should be considered before transpetrosal surgery in which the superior petrosal sinus may be obliterated.
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Affiliation(s)
- Ken Matsushima
- *Department of Neurological Surgery, University of Florida, Gainesville, Florida; ‡Department of Neurosurgery, Ohnishi Neurological Center, Hyogo, Japan; §Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
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Cranial dural arteriovenous shunts. Part 1. Anatomy and embryology of the bridging and emissary veins. Neurosurg Rev 2014; 38:253-63; discussion 263-4. [PMID: 25468011 DOI: 10.1007/s10143-014-0590-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 06/22/2014] [Indexed: 10/24/2022]
Abstract
We reviewed the anatomy and embryology of the bridging and emissary veins aiming to elucidate aspects related to the cranial dural arteriovenous fistulae. Data from relevant articles on the anatomy and embryology of the bridging and emissary veins were identified using one electronic database, supplemented by data from selected reference texts. Persisting fetal pial-arachnoidal veins correspond to the adult bridging veins. Relevant embryologic descriptions are based on the classic scheme of five divisions of the brain (telencephalon, diencephalon, mesencephalon, metencephalon, myelencephalon). Variation in their exact position and the number of bridging veins is the rule and certain locations, particularly that of the anterior cranial fossa and lower posterior cranial fossa are often neglected in prior descriptions. The distal segment of a bridging vein is part of the dural system and can be primarily involved in cranial dural arteriovenous lesions by constituting the actual site of the shunt. The veins in the lamina cribriformis exhibit a bridging-emissary vein pattern similar to the spinal configuration. The emissary veins connect the dural venous system with the extracranial venous system and are often involved in dural arteriovenous lesions. Cranial dural shunts may develop in three distinct areas of the cranial venous system: the dural sinuses and their interfaces with bridging veins and emissary veins. The exact site of the lesion may dictate the arterial feeders and original venous drainage pattern.
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McLaughlin N, Martin NA. Extended subtemporal transtentorial approach to the anterior incisural space and upper clival region: experience with posterior circulation aneurysms. Neurosurgery 2014; 10 Suppl 1:15-23; discussion 23-4. [PMID: 24064480 DOI: 10.1227/neu.0000000000000175] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although most posterior circulation aneurysms are currently treated by endovascular means, some are not amenable to this treatment modality. The narrow working window afforded by the anterolateral and lateral surgical approaches often translates into suboptimal visualization and limited maneuverability. OBJECTIVE We present a modified technique of tentorial incision and reflection that optimizes the exposure achieved with the traditional subtemporal approach and report our clinical experience in a series of posterior circulation aneurysms. METHODS Retrospective review of patients operated via an extended subtemporal transtentorial approach for posterior circulation aneurysms. The modified tentorial incision implies dissection of the trochlear nerve along its dural canal up to its entrance into the cavernous sinus and incision of a tentorial flap that extends up to Meckel cave, which is then reflected far anterolaterally. Clinical and radiological data were reviewed. RESULTS This series comprises 18 patients (21 procedures). Ten patients presented (56%) with a subarachnoid hemorrhage. Aneurysms most frequently arose from the basilar tip (61%) and were of small size (50%) and saccular morphology (72%). Two patients underwent surgery following unsuccessful endovascular treatment. Aneurysm treatment was successful on the first attempt in 90% (19/21) and after a second attempt in 10% (2/21). Documented postoperative palsies of the oculomotor (n = 3) and trochlear (n = 1) nerves were all transient. No procedure-related mortality occurred. CONCLUSION This modified technique of tentorial incision and reflection optimizes visibility, anatomic orientation, and maneuverability by increasing the rostrocaudal and anterolateral exposure obtained via the extended subtemporal transtentorial route without permanent postoperative trochlear nerve deficit.
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Affiliation(s)
- Nancy McLaughlin
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California
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Matsushima T, Kawashima M, Inoue K, Matsushima K. Anatomy of the superior petrosal veins and their exposure and management during petrous apex meningioma surgery using the lateral suboccipital retrosigmoid approach. Neurosurg Rev 2014; 37:535-456. [PMID: 24781190 DOI: 10.1007/s10143-014-0548-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 11/05/2013] [Accepted: 01/19/2014] [Indexed: 10/25/2022]
Abstract
During surgeries in the upper cerebellopontine angle (CPA), the superior petrosal veins (SPVs) often act as obstacles; and their sectioning sometimes causes serious complications. In this study, we introduced a classification system for the SPVs wherein their tributaries were classified into four groups on the basis of their courses and draining areas. We furthermore explained the detailed anatomy of the vein of the cerebellopontine fissure, which is the largest tributary. In surgeries of petrous apex meningioma, the knowledge of the displacement pattern of the vein is very helpful for avoiding major venous complications. Therefore, we elucidated its anatomical situation in relation to the original portion of the meningioma and the natural draining point of the vein into the superior petrosal sinus (SPS) in each patient. In addition, we described the methods and techniques used to expose and manage the vein of the cerebellopontine fissure during surgery using the lateral suboccipital retrosigmoid approach. Presenting two illustrative cases, we recommend that the initial exposure of the tumor should be performed through the infratentorial lateral supracerebellar route and that the suprafloccular cistern is the best area to find the vein of the cerebellopontine fissure. We emphasized the importance of the preservation of the vein of the cerebellopontine fissure and also proposed the order for exposure of SPV tributaries during upper CPA surgery using the retrosigmoid approach.
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Affiliation(s)
- Toshio Matsushima
- Department of Neurosurgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga-shi, Saga, 849-8501, Japan,
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Tubbs RS, Mortazavi MM, Krishnamurthy S, Verma K, Griessenauer CJ, Cohen-Gadol AA. The relationship between the superior petrosal sinus and the porus trigeminus: an anatomical study. J Neurosurg 2013; 119:1221-5. [DOI: 10.3171/2013.4.jns122062] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
During intracranial approaches to the skull base, vascular relationships are important. One relationship that has received scant attention in the literature is that between the superior petrosal sinus (SPS) and the opening of the Meckel cave (that is, the porus trigeminus).
Methods
Cadaver dissections were performed in 25 latex-injected adult cadaveric heads (50 sides). Specifically, the relationship between the SPS and the opening of the Meckel cave was observed. The goal was to enhance knowledge of the relationship between the SPS and the opening of the Meckel cave.
Results
Of the 50 sides, 68%, 18%, and 16% of SPSs traveled superior to, inferior to, and around the opening to the Meckel cave, respectively. In the latter cases, a venous ring was formed around the proximal trigeminal nerve. No sinus entered the Meckel cave. In general, the porus trigeminus was narrowed on sides found to have an SPS that encircled this region. Sinuses that traveled only inferior to the porus were in general smaller than sinuses that traveled superior or encircled this opening. No statistically significant differences were noted between the various sinus relationships and sex, age, or side of the head.
Conclusions
Knowledge of the relationship between the SPS and the opening of the Meckel cave may be useful to the skull base surgeon. Based on this study, some individuals may retain the early embryonic position of their SPS in relation to the trigeminal nerve.
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Affiliation(s)
- R. Shane Tubbs
- 1Pediatric Neurosurgery, Children's Hospital, Birmingham
| | | | | | - Ketan Verma
- 1Pediatric Neurosurgery, Children's Hospital, Birmingham
| | | | - Aaron A. Cohen-Gadol
- 3Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Kaku S, Miyahara K, Fujitsu K, Hataoka S, Tanino S, Okada T, Ichikawa T, Abe T. Drainage Pathway of the Superior Petrosal Vein Evaluated by CT Venography in Petroclival Meningioma Surgery. J Neurol Surg B Skull Base 2013; 73:316-20. [PMID: 24083122 DOI: 10.1055/s-0032-1321509] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 03/28/2012] [Indexed: 10/28/2022] Open
Abstract
Objectives This study aimed to clarify the drainage location of the superior petrosal vein (SPV) in relation to Meckel's cave and the internal acoustic meatus (IAM) and to discuss its significance in petroclival meningioma surgery. Design Prospective clinical study. Setting Hospital-based. Participants Five patients with petroclival meningioma and 50 patients (primarily unruptured supratentorial aneurysm patients, with a few hemifacial spasm patients) with no posterior fossa lesions. Main Outcome Measures On computed tomography venography (CTV), the drainage site was classified into three patterns based on its relationship to Meckel's cave and the IAM: Meckel's cave type, Intermediate type, and Meatal type. Results In all patients, the SPV was patent and emptied into the superior petrosal sinus (SPS). In patients without posterior fossa lesions, 35% had Meckel's cave type, 54% had Intermediate type, and 11% had Meatal type. Of the five patients with petroclival meningioma, three had Intermediate type, and two had Meckel's cave type. Conclusion The SPV is a significant vein that should be preserved to prevent venous complications. Preoperative knowledge of the SPV drainage site is helpful for planning the approach and preserving the SPV in petroclival meningioma surgery.
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Affiliation(s)
- Shougo Kaku
- Department of Neurosurgery, National Hospital Organization, Yokohama Medical Center, Kanagawa, Japan
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Watanabe T, Igarashi T, Fukushima T, Yoshino A, Katayama Y. Anatomical variation of superior petrosal vein and its management during surgery for cerebellopontine angle meningiomas. Acta Neurochir (Wien) 2013; 155:1871-8. [PMID: 23990034 PMCID: PMC3779012 DOI: 10.1007/s00701-013-1840-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 08/02/2013] [Indexed: 11/29/2022]
Abstract
No systematic study is yet available that focuses on the surgical anatomy of the superior petrosal vein and its significance during surgery for cerebellopontine angle meningiomas. The aim of the present study was to examine the variation of the superior petrosal vein via the retrosigmoid suboccipital approach in relation to the tumor attachment of cerebellopontine angle meningiomas as well as postoperative complications related to venous occlusion. Forty-three patients with cerebellopontine angle meningiomas were analyzed retrospectively. Based on the operative findings, the tumors were classified into four subtypes: the petroclival type, tentorial type, anterior petrous type, and posterior petrous type. According to a previous anatomical report, the superior petrosal veins were divided into three groups: Type I which emptied into the superior petrosal sinus above and lateral to the internal acoustic meatus, Type II which emptied between the lateral limit of the trigeminal nerve at Meckel's cave and the medial limit of the facial nerve at the internal acoustic meatus, and Type III which emptied into the superior petrosal sinus above and medial to Meckel's cave. In both the petroclival and anterior petrous types, the most common vein was Type III which is the ideal vein for a retrosigmoid approach. In contrast, the Type II vein which is at high risk of being sacrificed during a suprameatal approach procedure was most frequent in posterior petrous type, in which the superior petrosal vein was not largely an obstacle. Intraoperative sacrificing of veins was associated with a significantly higher rate of venous-related phenomena, while venous complications occurred even in cases where the superior petrosal vein was absent or compressed by the tumor. The variation in the superior petrosal vein appeared to differ among the tumor attachment subtypes, which could permit a satisfactory surgical exposure without dividing the superior petrosal vein. In cases where the superior petrosal vein was previously occluded, other bridging veins could correspond with implications for the crucial venous drainage system, and should thus be identified and protected whenever possible.
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Affiliation(s)
- Takao Watanabe
- Department of Neurological Surgery, Nihon University School of Medicine, 30-1 Oyaguchi-kamimachi, Itabashi-ku, Tokyo, 173-8610, Japan,
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McLaughlin N, Ma Q, Emerson J, Malkasian DR, Martin NA. The extended subtemporal transtentorial approach: the impact of trochlear nerve dissection and tentorial incision. J Clin Neurosci 2013; 20:1139-43. [PMID: 23743353 DOI: 10.1016/j.jocn.2012.11.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 11/08/2012] [Indexed: 10/26/2022]
Abstract
The subtemporal transtentorial approach provides excellent exposure of the incisural space. Incision of the tentorium improves access to the interpeduncular cistern, basilar artery, and rostral ventral pons. Description of the starting and termination points of the tentorial incision has varied greatly. We assessed the impact on surgical exposure of freeing the trochlear nerve (TN) from its dural canal (DC) in addition to dividing and retracting the tentorium. A subtemporal approach was performed on 10 hemispheres of cadaveric specimens. Following exposure of the middle tentorial incisura, the TN is dissected from its DC over a few millimeters. Two retraction sutures are placed along the tentorial edge, posterior to the TN entrance in its DC. The tentorial incision is started between the sutures. Dissection of TN from its DC continues for a short distance. The tentorial incision is extended straight up towards the superior petrosal sinus. Dissection of the TN DC continues anteriorly, up to its entry into the cavernous sinus. The tentorial incision can then be extended, just over the entrance to Meckel's cave, and the flap reflected far anterolateraly. Using this technique, the exposure of the interpeduncular cistern and its content increased by a mean of 8.2 mm (standard deviation [SD] 3.9 mm) in the anteroposterior axis and by 5.5mm (SD 1.9 mm) in the rostrocaudal axis. Tentorial incision following dissection of the TN from its DC optimizes reflection of the tentorium flap anterolateraly, maximizes the exposure, and improves lighting and visibility as well as maneuverability within the interpeduncular and rostral pre-pontine cisterns.
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Affiliation(s)
- Nancy McLaughlin
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Ronald Reagan Medical Center, Los Angeles, CA 90095-7436, USA
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Yang J, Liu YH, Ma SC, Wei L, Lin RS, Qi JF, Hu YS, Yu CJ. Subtemporal transtentorial petrosalapex approach for giant petroclival meningiomas: analyzation and evaluation of the clinical application. J Neurol Surg B Skull Base 2013; 73:54-63. [PMID: 23372996 DOI: 10.1055/s-0032-1304557] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Accepted: 08/10/2011] [Indexed: 10/28/2022] Open
Abstract
With the advent of microsurgery and surgical techniques, along with the improvement in neuroimaging techniques and the microanatomy in cadaver study, improvement in terms of surgical morbidity and mortality has been remarkable; however, controversy still exists regarding the optimal surgical strategies for giant petroclival meningiomas (GPMs). We report a study of clinical and radiological features as well as the surgical findings and outcomes for patients with GPM treated at our institution over the past 6 years. During a 6-year period (April 2004 to March 2010), 16 patients with GPM underwent surgery by subtemporal transtentorial petrosal apex approach during which electrophysiological monitoring of cranial nerves and brainstem function were reviewed. There were nine females and seven males with a mean age of 56.9 years (range from 32 to 78 years). The most frequent clinical manifestations were headache (93.7%) and dizziness (93.7%). Regions and directions of tumor extension include clivus, parasellar, and cavernous sinus, as well as compression of brainstem, and so on. The trochlear nerve was totally wrapped in nine cases (56.2%). The postoperative Karnofsky Performance Scale (KPS) score was 76.3 ± 13.1. Mean maximum diameter of the tumors on magnetic resonance imaging was 5.23 cm (range, 4.5 to 6.2 cm). Subtemporal transtentorial petrosalapex approach was performed in all 16 cases. Gross total resection was achieved in 14 cases (87.5%) and subtotal resection in 2 cases (12.5%) with no resultant mortality. Follow-up data were available for all 16 patients, with a mean follow-up period of 28.8 months (range from 4 to 69 months), of which 11 (68.75%) lived a normal life (KPS, 80-100). Our suggestion is that GPM could be completely resected by subtemporal transtentorial petrosalapex approach. The surgical strategy of GPM should be focused on survival and postoperative quality of life. Microneurosurgical technique plays a key role in tumor resection and preservation of nerve function. Intraoperative electrophysiological monitoring also contributes dramatically to the preservation of the nerve function. Complete resection of the tumor should be attempted at the first operation. Any remnant is treated by radiosurgery.
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Affiliation(s)
- Jun Yang
- Department of Neurosurgery, Fuxing Hospital, Capital University of Medical Sciences, The Third Neurosurgical Department of Capital University of Medical Science, Beijing
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Abstract
OBJECTIVE To study the microsurgical anatomy of the superior petrosal venous complex (SPVC). MATERIAL AND METHODS We conducted a descriptive and prospective study. Six injected specimens were used (12 sides). The microsurgical anatomy of the SPVC was studied by means of an anterior, retrosigmoid and transpetrosal approach. Neurosurgical equipment, 0-degree rigid endoscopy and OPMI-1 surgical microscope with 6× to 20× magnification were all used in this study. The venous drainage pattern toward the superior petrosal sinus was analysed, as were the formation of tributary veins, the relationship with the trigeminal nerve and the anatomical variants of SPVC. RESULTS The SPVC was present in all cases. A tributary, cerebellopontine fissure vein was identified in 100% of cases. The venous drainage pattern of the SPVC was divided into medial, intermediate and lateral with respect to the suprameatal crest. The SPVC was simple in 8 sides and duplicate in 4 sides. A triangle formed by the tentorium, the SPVC and part of the tentorial and petrosal surface of the cerebellum was also observed in the study. This triangle was called the petrosal-tentorial triangle. CONCLUSIONS It is important to understand the microsurgical anatomy of the SPVC. Therefore, we propose the petrosal-tentorial triangle as a neurosurgical route for the management of pathologies from the cerebellopontine angle to the superior petroclival region.
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Jittapiromsak P, Wu A, Nakaji P, Spetzler RF, Preul MC. The challenge of access to the pontomesencephalic junction: an anatomical study of lateral approach and exposure. Skull Base 2011; 20:311-20. [PMID: 21358994 DOI: 10.1055/s-0030-1249571] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We quantitatively compared relative merits of lateral approaches to the pontomesencephalic junction (PMJ): anterior petrosectomy, subtemporal transtentorial, posterior petrosectomy, and retrosigmoid transtentorial. In dissected cadaveric heads, lengths of exposure were measured anteriorly from CN V along the pontomesencephalic sulcus (PMS); posterosuperiorly along the lateral mesencephalic sulcus (LMS); and posteroinferiorly along the interpeduncular sulcus (IPS). Subtemporal transtentorial approach provided best anterior exposure along the PMS (23.8 ± 4.5 mm). Posterosuperior exposures were comparable for all approaches except anterior petrosectomy (limited). Posteroinferior exposure was most with subtemporal transtentorial approach (13.2 ± 2.8 mm). CN V entry/exit point was identified through all approaches, except for subtemporal transtentorial; shortest surgical depth with posterior petrosectomy was 43.7 ± 5.5 mm. PMS-LMS-IPS convergence point: reached through all approaches, except for anterior petrosectomy (limited); shortest surgical depth with posterior petrosectomy was 40.3 ± 4.3 mm. Anterior petrosectomy provides direct anterolateral views of the pons not afforded by subtemporal approach. Subtemporal transtentorial approach provides optimal posterolateral view to the PMJ and cerebellar peduncles. Retrosigmoid transtentorial approach offers wide exposure of the lateral surface, limited on the posteroinferior PMJ by the cerebellum. The small opening of posterior petrosectomy creates an awkward corridor to anterior PMJ targets but provides a direct and shortest route to the cerebellar peduncles.
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Affiliation(s)
- Pakrit Jittapiromsak
- Division of Neurological Surgery, Chulalongkorn Hospital, Chulalongkorn University, Bangkok, Thailand
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de Notaris M, Cavallo LM, Prats-Galino A, Esposito I, Benet A, Poblete J, Valente V, Gonzalez JB, Ferrer E, Cappabianca P. Endoscopic endonasal transclival approach and retrosigmoid approach to the clival and petroclival regions. Neurosurgery 2010; 65:42-50; discussion 50-2. [PMID: 19935001 DOI: 10.1227/01.neu.0000347001.62158.57] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE The removal of clival lesions, mainly those located intradurally and with a limited lateral extension, may be challenging because of the lack of a surgical corridor that would allow exposure of the entire lesion surface. In this anatomic study, we explored the clival/petroclival area and the cerebellopontine angle via both the endonasal and retrosigmoid endoscopic routes, aiming to describe the respective degree of exposure and visual limitations. METHODS Twelve fresh cadaver heads were positioned to simulate a semisitting position, thus enabling the use of both endonasal and retrosigmoid routes, which were explored using a 4-mm rigid endoscope as the sole visualizing tool. RESULTS The comparison of the 2 endoscopic surgical views (endonasal and retrosigmoid) allowed us to define 3 subregions over the clival area (cranial, middle, and caudal levels) when explored via the endonasal route. The definition of these subregions was based on the identification of some anatomic landmarks (the internal carotid artery from the lacerum to the intradural segment, the abducens nerve, and the hypoglossal canal) that limit the bone opening via the endonasal route and the natural well-established corridors via the retrosigmoid route. CONCLUSION Different endoscopic surgical corridors can be delineated with the endonasal transclival and retrosigmoid approaches to the clival/petroclival area. Some relevant neurovascular structures may limit the extension of the approach and the view via both routes. The combination of the 2 approaches may improve the visualization in this challenging area.
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Affiliation(s)
- Matteo de Notaris
- Division of Neurosurgery, Department of Neurological Sciences, Università degli Studi di Napoli Federico II, Naples, Italy
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Tanriover N, Sanus GZ, Ulu MO, Tanriverdi T, Akar Z, Rubino PA, Rhoton AL. Middle fossa approach: microsurgical anatomy and surgical technique from the neurosurgical perspective. ACTA ACUST UNITED AC 2009; 71:586-96; discussion 596. [DOI: 10.1016/j.surneu.2008.04.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2007] [Accepted: 04/15/2008] [Indexed: 11/17/2022]
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