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Kurucz P, Ganslandt O, Buchfelder M, Barany L. Microsurgical anatomy and pathoanatomy of the outer arachnoid membranes in the cerebellopontine angle: cadaveric and intraoperative observations. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05601-x. [PMID: 37133788 DOI: 10.1007/s00701-023-05601-x] [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: 01/25/2023] [Accepted: 04/17/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE The cerebellopontine angle (CPA) is a frequent region of skull base pathologies and therefore a target for neurosurgical operations. The outer arachnoid is the key structure to approach the here located lesions. The goal of our study was to describe the microsurgical anatomy of the outer arachnoid of the CPA and its pathoanatomy in case of space-occupying lesions. METHODS Our examinations were performed on 35 fresh human cadaveric specimens. Macroscopic dissections and microsurgical and endoscopic examinations were performed. Retrospective analysis of the video documentations of 35 CPA operations was performed to describe the pathoanatomical behavior of the outer arachnoid. RESULTS The outer arachnoid cover is loosely attached to the inner surface of the dura of the CPA. At the petrosal surface of the cerebellum the pia mater is strongly adhered to the outer arachnoid. At the level of the dural penetration of the cranial nerves, the outer arachnoid forms sheath-like structures around the nerves. In the midline, the outer arachnoid became detached from the pial surface and forms the base of the posterior fossa cisterns. In pathological cases, the outer arachnoid became displaced. The way of displacement depends on the origin of the lesion. The most characteristic patterns of changes of the outer arachnoid were described in case of meningiomas, vestibular schwannomas, and epidermoid cysts of the CPA. CONCLUSION The knowledge of the anatomy of the outer arachnoid of the cerebellopontine region is essential to safely perform microsurgical approaches as well as of dissections during resection of pathological lesions.
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Affiliation(s)
- Peter Kurucz
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanalage 60, 91054, Erlangen, Germany.
- Department of Neurosurgery, Katharinenhospital, Klinikum Stuttgart, Stuttgart, Germany.
| | - Oliver Ganslandt
- Department of Neurosurgery, Katharinenhospital, Klinikum Stuttgart, Stuttgart, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanalage 60, 91054, Erlangen, Germany
| | - Laszlo Barany
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanalage 60, 91054, Erlangen, Germany
- Laboratory for Applied and Clinical Anatomy, Department of Anatomy, Histology and Embryology, Semmelweis University, Budapest, Hungary
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Serioli S, Buffoli B, Maroldi R, Mattogno P, Gaudino S, Lauretti L, Rezzani R, Olivi A, Fontanella MM, Rigante M, Doglietto F. The Oculomotor Cistern and Its Role in the Management of Pituitary Lesions: An Anatomical, Radiographic, and Clinical Scoping Review. World Neurosurg 2023; 172:12-19. [PMID: 36657712 DOI: 10.1016/j.wneu.2023.01.048] [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: 11/12/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND The oculomotor cistern (OMC) is a cerebrospinal fluid space bound by meningeal layers that surrounds the oculomotor nerve as it crosses the oculomotor triangle to reach the lateral wall of the cavernous sinus at the level of the anterior clinoid process. Although several anatomical and radiological studies are available, its anatomy and relationship with pituitary adenomas (PAs) are still matter of discussion. OBJECTIVE The aim of the study is to provide an updated and focused overview of the OMC, highlighting the different perspectives and descriptions from anatomical, radiological, and clinical points of view. METHODS A scoping review was conducted up to 29th October 2022, according to PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) criteria. PubMed, Web of Science, Scopus databases, and correlated citations were investigated. RESULTS Of the 562 records identified, 22 were included in the present analysis. There were 13, 5, and 4 anatomo-surgical, radiological, and clinical studies, respectively. Though there is general consensus on its definition, data are variable on different features of OMC. Defects or absence of dural layers adjacent to the oculomotor nerve were described in only 4 papers. The transition from meningeal to neural layers is still unclear. PAs with OMC involvement are poorly studied and have unique clinical characteristics. To date, 21 patients have been described; the reported prevalence of OMC involvement by PAs ranges from 4.1% to 14.6%. CONCLUSIONS Clarifying the OMC features with further systematic studies may not only broaden theoretical knowledge but also have implications on endoscopic transnasal pituitary surgery.
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Affiliation(s)
- Simona Serioli
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Spedali Civili of Brescia, University of Brescia, Brescia, Italy.
| | - Barbara Buffoli
- Department of Clinical and Experimental Sciences, Section of Anatomy and Physiopathology, University of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Division of Radiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Pierpaolo Mattogno
- Institute of Neurosurgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Simona Gaudino
- Department of Radiological Sciences, Institute of Radiology, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Liverana Lauretti
- Institute of Neurosurgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Rita Rezzani
- Department of Clinical and Experimental Sciences, Section of Anatomy and Physiopathology, University of Brescia, Brescia, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Mario Rigante
- Otorhinolaryngology and Head-Neck Surgery Unit, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Doglietto
- Institute of Neurosurgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
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Kumar T, Virador GM, Brahmbhatt P, Bhatt AA, Middlebrooks EH, Desai A, Agarwal A, Vibhute P, Gupta V. High-Resolution 7T MR Imaging of the Trochlear Nerve. AJNR Am J Neuroradiol 2023; 44:186-191. [PMID: 36657953 PMCID: PMC9891327 DOI: 10.3174/ajnr.a7774] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/31/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE The trochlear nerve has traditionally been difficult to identify on MR imaging. The advent of 7T MR imaging promises to greatly benefit visualization of small structures due to gains in the signal-to-noise ratio allowing improved spatial resolution. We investigated the utility of a clinically feasible ultra-high-resolution 7T MR imaging protocol for identification of the trochlear nerve, as well as assessment of normal trochlear nerve anatomy. MATERIALS AND METHODS Coronal high-resolution 2D T2-weighted TSE images used in a 7T epilepsy protocol of 50 subjects at our institution were reviewed by 2 independent radiologists for visualization of the trochlear nerve at the nerve origin and cisternal, tentorial, and cavernous segments. The frequency of nerve visibility within these segments and their anatomy were documented, and disagreements were resolved by joint review. RESULTS Of the 100 nerves reviewed in 50 subjects, at least 2 segments of the trochlear nerve from the brainstem to the cavernous sinus were identified in 100% of cases. The origins from the brainstem and cisternal segment were visible in 65% and 93% of nerves, respectively. The trochlear nerve was identified at the trochlear groove in 100% of cases and in the posterior wall of the cavernous sinus in 74% of cases. CONCLUSIONS Coronal high-resolution 2D TSE at 7T reliably identified the trochlear nerve throughout its course and is a promising tool for imaging patients with suspected trochlear nerve pathology.
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Affiliation(s)
- T Kumar
- From the Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - G M Virador
- From the Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - P Brahmbhatt
- From the Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - A A Bhatt
- From the Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - E H Middlebrooks
- From the Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - A Desai
- From the Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - A Agarwal
- From the Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - P Vibhute
- From the Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - V Gupta
- From the Department of Radiology, Mayo Clinic, Jacksonville, Florida
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Ahmed AK, Gudapati K, Eggenberger ER, McGeary R, Gupta V, Vibhute P. Oculomotor nerve root split: incidental finding on MRI-case report and literature review. SURGICAL AND RADIOLOGIC ANATOMY : SRA 2022; 44:1379-1383. [PMID: 36178524 DOI: 10.1007/s00276-022-03024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 09/23/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The oculomotor nerve (OMN) innervates the pupil, ciliary body, upper eyelid, and extraocular muscles through two divisions: a superior division that innervates the levator palpebrae superioris (LPS) and superior rectus (SR), and an inferior division that supplies the medial rectus (MR), inferior rectus (IR), inferior oblique (IO), and parasympathetic fibers to the pupil and ciliary body. We present a case of complete splitting of the cisternal segment of bilateral OMNs that was discovered incidentally on magnetic resonance imaging (MRI) in a patient who had no ocular complaints. CASE REPORT A 69-year-old patient was found to have bilateral splitting of the cisternal segments of OMNs during an MRI for trigeminal neuralgia workup. Both nerves sprang from the midbrain as distinct roots. They were symmetric on the right and minimally asymmetric on the left. On both sides, the medial root was slightly inferiorly situated. The patient had no visual problems and continued to function normally. A review of the literature for similar cases identified no such variants; however, it did identify eight examples of OMN fenestrations produced by aneurysms (AN), six of which had no OMN palsy symptoms. CONCLUSION An anatomic variant of split bilateral OMN cisternal segments is described. The superior and inferior divisions may have different brainstem origins. Although this variant is an anatomic curiosity, it may have clinical significance and explain the various presentation of compressive OMN palsies.
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Affiliation(s)
- Ahmed K Ahmed
- Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Kaavya Gudapati
- Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | | | - Ryan McGeary
- Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Vivek Gupta
- Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Prasanna Vibhute
- Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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Morris JA, Gilbert BC, Parker WT, Forseen SE. Anatomy of the Ventricles, Subarachnoid Spaces, and Meninges. Neuroimaging Clin N Am 2022; 32:577-601. [PMID: 35843664 DOI: 10.1016/j.nic.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The ventricular system, subarachnoid spaces, and meninges are structures that lend structure, support, and protection to the brain and spinal cord. This article provides a detailed look at the anatomy of the intracranial portions of these structures with a particular focus on neuroimaging methods.
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Affiliation(s)
- John A Morris
- Department of Radiology and Imaging, Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, USA
| | - Bruce C Gilbert
- Neuroradiology, Neuroradiology Section, Department of Radiology and Imaging, Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, USA
| | - William T Parker
- Neuroradiology, Neuroradiology Section, Department of Radiology and Imaging, Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, USA
| | - Scott E Forseen
- Department of Radiology and Imaging, Medical College of Georgia at Augusta University, 1120 15th Street, Augusta, GA 30912, USA.
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Rai S, Srivastava S, Kamath M, Murlimanju BV, Parmar G, Chebrolu G. Delineation of Subarachnoid Cisterns Using CT Cisternography, CT Brain Positive and Negative Contrast, and a Three Dimensional MRI Sequence: A Pictorial Review. Cureus 2022; 14:e23741. [PMID: 35509744 PMCID: PMC9057636 DOI: 10.7759/cureus.23741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 11/10/2022] Open
Abstract
The basic anatomy and morphology of subarachnoid cisterns of the brain are interesting and challenging topics with high clinical significance. These enlarged CSF-filled expansions are important as they transmit various neurovascular structures. The cisterns can be classified based on their location as supratentorial, at the level of the tentorium, and infratentorial. They are also classified as paired and unpaired cisterns. The anatomical and radiological information about the cisterns is clinically and surgically relevant in diagnosing and managing many neurological disorders. It is also essential in medical teaching. This pictorial essay reviews the radiological images where the subarachnoid cisterns are delineated in four unique circumstances.
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Rennert R, Goodwill V, Steinberg J, Fukushima T, Day JD, Khalessi AA, Levy M. Histology of the Porous Oculomotorius: Relevance to Anterior Skull Base Approaches. J Neurol Surg B Skull Base 2022; 84:210-216. [PMID: 37180869 PMCID: PMC10171935 DOI: 10.1055/a-1780-4619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/17/2022] [Indexed: 10/19/2022] Open
Abstract
Objective: Mobilization of cranial nerve III (CNIII) at its dural entry site is commonly described to avoid damage from stretching during approaches to the parasellar, infrachiasmatic, posterior clinoid, and cavernous sinus regions. The histologic relationships of CNIII as it traverses the dura, and the associated surgical implications are nonetheless poorly described. We herein assess the histology of the CNIII-dura interface as it relates to surgical mobilization of the nerve.
Methods: A fronto-orbitozygomatic temporopolar approach was performed on six adult cadaveric specimens. The CNIII-dural entry site was resected and histologically processed. The nerve-tissue planes were assessed by a neuropathologist.
Results: Histologic analysis demonstrated that CNIII remained separate from the dura within the oculomotor cistern (porous oculomotorius up to the oculomotor foramen). Fusion of the epineurium of CNIII and the connective tissue of the dura was seen at the level of the foramen, with no clear histologic plane identified between these structures.
Conclusion: CNIII may be directly mobilized within the oculomotor cistern, while dissections of CNIII distal to the oculomotor foramen should maintain a thin layer of connective tissue on the nerve.
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Affiliation(s)
- Robert Rennert
- Neurosurgery, University of California San Diego Health System, La Jolla, United States
| | - Vanessa Goodwill
- Pathology, University of California San Diego Health System, La Jolla, United States
| | - Jeffrey Steinberg
- Neurosurgery, University of California San Diego Health System, La Jolla, United States
| | | | - John D. Day
- Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, United States
| | | | - Michael Levy
- Rady Children's Hospital San Diego, San Diego, United States
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Parashar V, Mathur V. Cisternal oculomotor schwannoma: a rare cause of anisocoria with ptosis in a child. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2022. [DOI: 10.1186/s41983-021-00438-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Primary nerve sheath tumor of cranial nerve is a rare intracranial space occupying lesion that most commonly involves vestibular nerve. Oculomotor nerve schwannoma, without neurofibromatosis, is an extremely uncommon entity especially in children. Though any cranial nerve can be involved by schwannoma except I and II nerve as these cranial nerves lack a Schwann cell sheath.
Case presentation
We herein report a 14-year-old boy presenting with an oculomotor schwannoma in the absence of features of neurofibromatosis, manifesting as progressive diplopia, ptosis, and blurring of vision.
Conclusions
Most similar previous case reports in literature reported oculomotor schwannoma in adults, unlike our case. The detection rate of such rare lesions has, however, increased in the last two decades due to neuroimaging advances.
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Jeeva-Patel T, Mandell D, Le T, Margolin E. Radiation-Induced Third Cranial Nerve Palsy With the Longest Interval Between Radiation Therapy and Onset of Cranial Neuropathy. J Neuroophthalmol 2021; 41:e331-e332. [PMID: 32956227 DOI: 10.1097/wno.0000000000001081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Trishal Jeeva-Patel
- Department of Ophthalmology and Vision Sciences (TJ-P, TL, EM), University of Toronto, Toronto, Canada ; Department of Medical Imaging (DM), University of Toronto, Toronto, Canada ; and Division of Neurology (EM), Department of Medicine, University of Toronto, Toronto, Canada
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Rama Raj P, Smith V. Anatomical Basis of Clinical Manifestations Seen in Cavernous Sinus Syndrome: A Narrative Review. Open Ophthalmol J 2021. [DOI: 10.2174/1874364102115010070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pathology involving the Cavernous Sinus (CS), generally referred to as Cavernous Sinus Syndrome (CSS), can arise from vascular disorders, neoplasms, infections, and non-infectious inflammatory disorders. An acute understanding of the CS and its regional anatomical structures is therefore pertinent in expounding the highly variable clinical manifestations seen in CSS as well as laying the groundwork for surgical intervention. Though the neuroanatomy of the cavernous sinus has been substantially chronicled in literature, their correlation to clinical signs has only been minimally described. This narrative review serves to address this knowledge gap and aims to comprehensively correlate the clinical manifestations of CSS with the relevant neuroanatomy, thereby allowing medical practitioners to better navigate the diagnostic quandary. We conducted a scoping review of the literature concerning CS anatomy and CSS, complied through MEDLINE/OVID and cross-referencing of articles on PubMed and Google Scholar with the keywords cavernous sinus, cavernous sinus syndrome, clinical signs/manifestations, neuroanatomy, CS pathology, Cavernous Sinus Thrombus (CST) and cavernous sinus neoplasms/tumours.
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Arachnoid and dural reflections. HANDBOOK OF CLINICAL NEUROLOGY 2021; 169:17-54. [PMID: 32553288 DOI: 10.1016/b978-0-12-804280-9.00002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
The dura mater is the major gateway for accessing most extra-axial lesions and all intra-axial lesions of the central nervous system. It provides a protective barrier against external trauma, infections, and the spread of malignant cells. Knowledge of the anatomical details of dural reflections around various corners of the skull bases provides the neurosurgeon with confidence during transdural approaches. Such knowledge is indispensable for protection of neurovascular structures in the vicinity of these dural reflections. The same concept is applicable to arachnoid folds and reflections during intradural excursions to expose intra- and extra-axial lesions of the brain. Without a detailed understanding of arachnoid membranes and cisterns, the neurosurgeon cannot confidently navigate the deep corridors of the skull base while safely protecting neurovascular structures. This chapter covers the surgical anatomy of dural and arachnoid reflections applicable to microneurosurgical approaches to various regions of the skull base.
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Sasagawa Y, Aburano H, Ooiso K, Oishi M, Hayashi Y, Nakada M. Oculomotor nerve palsy in pituitary apoplexy associated with pituitary adenoma: a radiological analysis with fast imaging employing with steady-state acquisition. Acta Neurochir (Wien) 2021; 163:383-389. [PMID: 33128620 DOI: 10.1007/s00701-020-04632-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/23/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Oculomotor nerve palsy (ONP) occasionally occurs in cases of pituitary apoplexy (PA) associated with pituitary adenoma, but its mechanism remains unclear. Intracranial nerves are clearly visualized by fast-imaging employing with steady-state acquisition (FIESTA). Here, we assessed the oculomotor nerve compression in patients with PA associated with pituitary adenoma using FIESTA. METHODS Twenty-eight cases of PA, with or without ONP, were retrospectively reviewed. All patients had undergone preoperative FIESTA. Two neuroradiologists, unaware of the patient's clinical symptoms, evaluated the presence and location of oculomotor nerve compression due to the tumor. RESULTS Thirteen of the twenty-eight PA cases were associated with ONP. Tumor size and degree of cavernous sinus invasion were not significantly different between the ONP and non-ONP groups. Even in the ONP group, 8/13 (62%) tumors did not show cavernous sinus invasion. Via FIESTA, the presence of oculomotor nerve compression was confirmed in 11/13 (85%) and 5/15 (33%) cases in the ONP and non-ONP groups, respectively (p = 0.008). The radiologists' diagnoses of laterality of nerve compression (right or left) were consistent with the patient's affected eye. In the ONP group, the location of the nerve compression was located at the entry point to the cavernous sinus, the so-called oculomotor triangle, in 9/11 (82%) cases and intra cavernous sinus in 2/11 (18%) cases. CONCLUSION Compression at the oculomotor triangle is considered the main cause of ONP with PA in pituitary adenomas.
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Condos A, Sullivan MA, Hawley D, Cho A, Cathey M. Not Just Down and Out: Oculomotor Nerve Pathologic Spectrum. Curr Probl Diagn Radiol 2021; 51:217-224. [PMID: 33495031 DOI: 10.1067/j.cpradiol.2020.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 11/24/2020] [Accepted: 12/31/2020] [Indexed: 11/22/2022]
Abstract
The purpose of this article is to understand the complex pathologic spectrum of oculomotor nerve palsy. We review the detailed anatomy and function of the oculomotor nerve and demonstrate how the location of a lesion can drive the differential diagnosis. Lastly, we review atypical presentations of oculomotor nerve palsy to include oculomotor synkinesis and oculomotor nerve hyperactivity. Radiologists must be aware of the typical and atypical presentations of CN III palsy to accurately localize lesions as well as avoid premature exclusion of CN III pathology.
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Sananmuang T, Boonsiriwattanakul C, Panyaping T. Signal intensity pattern of the normal oculomotor nerve on contrast-enhanced 3D FLAIR at 3.0 T MRI. Neuroradiol J 2020; 34:99-104. [PMID: 33176571 DOI: 10.1177/1971400920970918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The aim of this study was to depict the signal intensity pattern of the normal oculomotor nerve demonstrated on contrast-enhanced three-dimensional fluid-attenuated inversion recovery images. MATERIALS AND METHODS Eighty-one patients were included in the study. Contrast-enhanced three-dimensional fluid-attenuated inversion recovery images with magnetisation-prepared rapid acquisition were reconstructed and evaluated in the coronal plane. The signal intensity of the cisternal segment of the oculomotor nerve was graded into a visual scale of 1 to 5 as compared to the white matter, grey matter and the pituitary stalk. The signal intensity ratio of the oculomotor nerve was consequently measured. RESULTS By using the visual scale, more than half of the oculomotor nerves showed higher signal intensity than the grey matter signal on contrast-enhanced three-dimensional fluid-attenuated inversion recovery images (59.3-80.2%). It can demonstrate a signal intensity similar to the pituitary stalk (14.8%) by visualisation. None of them showed signal intensity equal to the normal white matter signal. By signal intensity measurement, the mean signal intensity ratio of oculomotor nerves to white matter equals 1.54±0.20 (95% confidence interval (CI) 1.51-1.57); mean signal intensity ratio to grey matter equals 1.16±0.15 (95% CI 1.14-1.18); mean signal intensity ratio to the pituitary stalk equals 0.68±0.10 (95% CI 0.64-0.70). CONCLUSIONS The normal oculomotor nerve visualised on contrast-enhanced three-dimensional fluid-attenuated inversion recovery images has a higher signal intensity than the white matter and may have a signal intensity similar to the grey matter or the pituitary stalk. The high signal intensity of the oculomotor nerve in contrast-enhanced three-dimensional fluid-attenuated inversion recovery should not be misinterpreted as a pathology.
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Affiliation(s)
- Thiparom Sananmuang
- Department of Diagnostic and Therapeutic Radiology, 432716Ramathibodi Hospital, Thailand
| | | | - Theeraphol Panyaping
- Department of Diagnostic and Therapeutic Radiology, 432716Ramathibodi Hospital, Thailand
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Zhao X, Labib MA, Shaffer KV, Moreira LB, Ramanathan D, Naeem K, Belykh E, Lawton MT, Lopez-Gonzalez MA, Preul MC. Tailoring the surgical corridor to the basilar apex in the pretemporal transcavernous approach: morphometric analyses of different neurovascular mobilization maneuvers. Acta Neurochir (Wien) 2020; 162:2731-2741. [PMID: 32757048 DOI: 10.1007/s00701-020-04490-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 07/10/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND The pretemporal transcavernous approach (PTA) provides optimal exposure and access to the basilar artery (BA); however, the PTA can be invasive when vital neurovascular structures are mobilized. The goal of this study was to evaluate mobilization strategies to tailor approaches to the BA. METHODS After an orbitozygomatic craniotomy, 10 sides of 5 cadaveric heads were used to assess the surgical access to the BA via the opticocarotid triangle (OCT), carotid-oculomotor triangle (COT), and oculomotor-tentorial triangle (OTT). Measurements were obtained, and morphometric analyses were performed for natural neurovascular positions and after each stepwise expansion maneuver. An imaginary line connecting the midpoints of the limbus sphenoidale and dorsum sellae was used as a reference to normalize the measurements of BA exposure and to facilitate the clinical applicability of this technique. RESULTS In the OCT, the exposed BA segment ranged from - 1 ± 3.9 to + 6 ± 2.0 mm in length in its natural position. In the COT, the accessible BA segment ranged from - 4 ± 2.3 to - 2 ± 3.0 mm in length in its natural position. Via the OTT, the accessible BA segment ranged from - 7 ± 2.6 to - 5 ± 2.8 mm in length in its natural position. In the OCT, COT, and OTT, a posterior clinoidectomy extended the exposure down to - 6 ± 2.7, - 8 ± 2.5, and - 9 ± 2.9 mm, respectively. CONCLUSIONS This study quantitatively evaluated the need for the expansion maneuvers in the PTA to reach BA aneurysms according to the patient's anatomical characteristics.
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Affiliation(s)
- Xiaochun Zhao
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Mohamed A Labib
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Kurt V Shaffer
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Leandro Borba Moreira
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Dinesh Ramanathan
- Department of Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Komal Naeem
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Evgenii Belykh
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Michael T Lawton
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | | | - Mark C Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA.
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Geethapriya S, Govindaraj J, Raghavan B, Ramakrishnan B, Arafath R, Vishwanathan S, Krishna M. Cranial nerve schwannoma - A pictorial essay. Indian J Radiol Imaging 2020; 30:116-125. [PMID: 33100678 PMCID: PMC7546302 DOI: 10.4103/ijri.ijri_17_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/13/2020] [Accepted: 04/09/2020] [Indexed: 01/25/2023] Open
Abstract
Schwannomas are peripheral nerve sheath tumours arising from cranial, spinal or peripheral nerves. Most of the schwannomas are benign with the rare possibility of malignant transformation. Cranial nerve schwannomas can be seen along the course of any cranial nerve in the intracranial region or head and neck location. Although a majority are solitary sporadic lesions, multiple schwannomas can be seen in syndromes like neurofibromatosis type 2 and rarely in type 1. Since intracranial schwannomas are slow-growing, clinical presentation varies between no symptoms to cranial nerve palsy. Most of the times, the symptoms are due to mass effect over the adjacent structures, foraminal widening, compression of other cranial nerves, denervation injury or hydrocephalus. Familiarity with the course of the cranial nerves, imaging appearances and clinical presentation of schwannomas helps in accurate diagnosis and possible differential diagnosis, especially in uncommon clinical and radiological appearances. In this pictorial review, we illustrate relevant anatomy of cranial nerves, imaging features of schwannomas of most of the cranial nerves, clinical presentation and differential diagnosis.
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Affiliation(s)
- Sivaramalingam Geethapriya
- Department of Radiology, Apollo Cancer Institutes, Padma Complex, Anna Salai, Chennai, Tamil Nadu, India
| | - Jayaraj Govindaraj
- Department of Radiology, Apollo Cancer Institutes, Padma Complex, Anna Salai, Chennai, Tamil Nadu, India
| | - Bagyam Raghavan
- Department of Radiology, Apollo Cancer Institutes, Padma Complex, Anna Salai, Chennai, Tamil Nadu, India
| | - Banupriya Ramakrishnan
- Department of Radiology, Apollo Cancer Institutes, Padma Complex, Anna Salai, Chennai, Tamil Nadu, India
| | - Rasheed Arafath
- Department of Radiology, Apollo Cancer Institutes, Padma Complex, Anna Salai, Chennai, Tamil Nadu, India
| | - Sathyashree Vishwanathan
- Department of Radiology, Apollo Cancer Institutes, Padma Complex, Anna Salai, Chennai, Tamil Nadu, India
| | - Murali Krishna
- Department of Radiology, Apollo Cancer Institutes, Padma Complex, Anna Salai, Chennai, Tamil Nadu, India
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Zhao X, Labib M, Ramanathan D, Eastin TM, Song M, Little AS, Preul MC, Lawton MT, Lopez-Gonzalez MA. The anterior incisural width as a preoperative indicator for intradural space evaluation: An anatomical investigation. Surg Neurol Int 2020; 11:207. [PMID: 32874710 PMCID: PMC7451160 DOI: 10.25259/sni_175_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 06/27/2020] [Indexed: 11/24/2022] Open
Abstract
Background: The opticocarotid triangle (OCT) and the carotico-oculomotor triangle (COT) are two anatomical triangles used in accessing the interpeduncular region. Our objective is to evaluate if the anterior incisural width (AIW) is an indicator to predict the intraoperative exposure through both triangles. Methods: Twenty sides of 10 cadaveric heads were dissected and analyzed. The heads were divided into the following: Group A – narrow anterior incisura and Group B – wide anterior incisura – using 26.6 mm as a cutoff distance of the AIW. Subsequently, the area of the COT and the OCT in the transsylvian approach was measured, along with the maximum widths through the two trajectories in modified superior transcavernous approach. Results: The COT in the wide group was shown to have a significantly larger area compared with the COT in the narrow group (38.4 ± 12.64 vs. 58.3 ± 15.72 mm, P < 0.01). No difference between the two groups was reported in terms of the area of the OCT (50.9 ± 19.22 mm vs. 63.5 ± 15.53 mm, P = 0.20), the maximum width of the OCT (6.6 ± 1.89 vs. 6.5 ± 1.38 mm, P = 1.00), or the maximum width of the COT (11.7 ± 2.06 vs. 12.2 ± 2.32 mm, P = 0.50). Clinical cases were included. Conclusion: An AIW <26.6 mm is an unfavorable factor related to a limited COT area in a transsylvian approach for pathologies at the interpeduncular fossa. Preoperative identification and measurement of a narrow AIW can suggest the need to add a transcavernous approach.
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Affiliation(s)
- Xiaochun Zhao
- Department of Neurosurgery, Barrow Neurological Institute, West Thomas Road, Phoenix, Arizona
| | - Mohamed Labib
- Department of Neurosurgery, Barrow Neurological Institute, West Thomas Road, Phoenix, Arizona
| | - Dinesh Ramanathan
- Department of Neurosurgery, Loma Linda University School of Medicine, California, United States
| | - Timothy Marc Eastin
- Department of Neurosurgery, Loma Linda University School of Medicine, California, United States
| | - Minwoo Song
- Department of Neurosurgery, Loma Linda University School of Medicine, California, United States
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, West Thomas Road, Phoenix, Arizona
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, West Thomas Road, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, West Thomas Road, Phoenix, Arizona
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Doi K, Otani N, Hagita D, Horiuchi M, Takeuchi S, Toyooka T, Wada K, Hayashi M, Mori K. A Case of Meningioma Originating from the Oculomotor Nerve. World Neurosurg 2020; 143:197-201. [PMID: 32702491 DOI: 10.1016/j.wneu.2020.07.089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/11/2020] [Accepted: 07/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Schwannoma originating from the oculomotor nerve has been reported. However, meningioma originating from this nerve was unknown. CASE DESCRIPTION A 22-year-old woman presented with a unique case of meningioma originating from the oculomotor nerve manifesting as periorbital pain and diplopia beginning 4 months previously. Oculomotor nerve schwannoma was suggested by several pretreatment examinations. Tumor resection was considered risky for preservation of the oculomotor nerve function; therefore, gamma knife surgery (GKS) was performed. Six months later, she suffered right complete ptosis and worsened blurry vision. Corticosteroid was administered, but her symptoms did not improve. Magnetic resonance imaging showed the tumor lesion had grown larger. We decided to resect the tumor lesion because of her uncontrolled periorbital pain. The tumor had occupied the oculomotor cistern and was gross totally removed. Histologic diagnosis was surprisingly transitional meningioma. The tumor lesion occupied the oculomotor cistern and was refractory to GKS, with a progressive clinical course, which is more suggestive of meningioma than schwannoma, although extremely rare. Her periorbital pain and blurry vision gradually regressed, whereas complete oculomotor nerve palsy persisted. CONCLUSIONS In such a case, tumor resection after GKS should be considered.
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Affiliation(s)
- Kazuma Doi
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan.
| | - Naoki Otani
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan; Department of Neurosurgery, Nihon University School of Medicine, Tokyo, Japan
| | - Daichi Hagita
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Midori Horiuchi
- Division of Neurology, Department of Internal Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Satoru Takeuchi
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Terushige Toyooka
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kojiro Wada
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Motohiro Hayashi
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Kentaro Mori
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan; Department of Neurosurgery, Tokyo General Hospital, Tokyo, Japan
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Kim HJ, Seong M, Kim Y. Normal Anatomy of Cranial Nerves III–XII on Magnetic Resonance Imaging. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2020; 81:501-529. [PMID: 36238638 PMCID: PMC9431917 DOI: 10.3348/jksr.2020.81.3.501] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/02/2020] [Indexed: 11/15/2022]
Abstract
복잡한 해부학적 구조와 기능 때문에 뇌신경 질환의 신경영상검사는 항상 어려운 과제이다. 최근 자기공명영상(이하 MRI) 기법의 발달로 많은 경우에서 뇌신경 질환의 원인이 규명되고 있으며, 신경영상의학 의사들은 다학제 팀의 핵심적 팀원으로서 다양한 뇌신경 질환의 원활한 진단을 위하여 MRI에서 관찰되는 뇌신경의 세밀한 해부학적 구조를 잘 알아야 한다. 이 종설에서는 말초성 뇌신경 III–XII에 대해 뇌간으로부터 두개 밖까지 해부학적으로 비슷한 구조를 가지는 구역별로 분류하여 각 구역에서 보이는 뇌신경의 정상 해부학 및 MRI 소견을 설명하고자 한다. 또한 각 구역에서 가장 적합한 MRI 기법에 관하여도 기술하고자 한다.
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Affiliation(s)
- Hyung-Jin Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Minjung Seong
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yikyung Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Churi ON, Gupta S, Misra BK. Correlation of Preoperative Cranial Nerve Diffusion Tensor Tractography with Intraoperative Findings in Surgery of Cerebellopontine Angle Tumors. World Neurosurg 2019; 127:e509-e516. [DOI: 10.1016/j.wneu.2019.03.190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 03/18/2019] [Accepted: 03/19/2019] [Indexed: 11/17/2022]
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Malloy KA, Draper EM, Maglione AK. Pupil-sparing third cranial nerve palsy with aberrant regeneration secondary to cavernous sinus arachnoid cyst. eNeurologicalSci 2019; 14:28-30. [PMID: 30555949 PMCID: PMC6276728 DOI: 10.1016/j.ensci.2018.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 11/17/2018] [Indexed: 11/28/2022] Open
Abstract
A 66 year-old woman presented with a pupil-sparing partial third cranial nerve palsy with aberrant regeneration. Imaging revealed a cystic lesion in the right cavernous sinus, demonstrating signal characteristics consistent with arachnoid cyst. Oculomotor synkinesis and a pupil-sparing third cranial nerve palsy from an arachnoid cyst of the cavernous sinus have not been previously reported. Intracavernous arachnoid cysts are in the differential diagnosis of cranial nerve III palsies, with and without synkinesis or pupil involvement. Case of pupil-sparing partial third cranial nerve palsy with aberrant regeneration. Oculomotor synkinesis attributed to arachnoid cyst of the cavernous sinus. Intracavernous arachnoid cysts can cause cranial nerve III palsies.
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Affiliation(s)
- Kelly A. Malloy
- Corresponding author at: Salus University, 8360 Old York Rd, Elkins Park, PA 19027, United States.
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Jacquesson T, Frindel C, Kocevar G, Berhouma M, Jouanneau E, Attyé A, Cotton F. Overcoming Challenges of Cranial Nerve Tractography: A Targeted Review. Neurosurgery 2018; 84:313-325. [PMID: 30010992 DOI: 10.1093/neuros/nyy229] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 05/01/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Timothée Jacquesson
- Skull Base Multi-disciplinary Unit, Department of Neurosurgery B, Neurological Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
- Department of Anatomy, University of Lyon 1, Lyon, France
- CREATIS Laboratory CNRS UMR5220, Inserm U1206, INSA-Lyon, University of Lyon 1, Lyon, France
| | - Carole Frindel
- CREATIS Laboratory CNRS UMR5220, Inserm U1206, INSA-Lyon, University of Lyon 1, Lyon, France
| | - Gabriel Kocevar
- CREATIS Laboratory CNRS UMR5220, Inserm U1206, INSA-Lyon, University of Lyon 1, Lyon, France
| | - Moncef Berhouma
- Skull Base Multi-disciplinary Unit, Department of Neurosurgery B, Neurological Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
- CREATIS Laboratory CNRS UMR5220, Inserm U1206, INSA-Lyon, University of Lyon 1, Lyon, France
| | - Emmanuel Jouanneau
- Skull Base Multi-disciplinary Unit, Department of Neurosurgery B, Neurological Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Arnaud Attyé
- Department of Radiology, Grenoble University Hospital, Grenoble, France
| | - Francois Cotton
- CREATIS Laboratory CNRS UMR5220, Inserm U1206, INSA-Lyon, University of Lyon 1, Lyon, France
- Department of Radiology, Lyon Sud Hospital, Hospices Civils de Lyon, Lyon, France
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Taniguchi M, Nakai T, Kimura H, Fujita Y, Uozumi Y, Kohta M, Kohmura E. Endoscopic endonasal surgery for pituitary adenomas extending to the oculomotor cistern. Head Neck 2017; 40:536-543. [PMID: 29120512 DOI: 10.1002/hed.24999] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/20/2017] [Accepted: 09/26/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Extension of a pituitary adenoma to the oculomotor cistern harbors the risk of oculomotor nerve impairment and further extension into the interpeduncular cistern. The role of endoscopic endonasal surgery for those lesions was investigated. METHODS The medical records were retrospectively analyzed. Attention was paid to the oculomotor nerve function and removal rate of the tumor within the oculomotor and interpeduncular cisterns. RESULTS Six patients were eligible for the study, including 2 with oculomotor nerve palsy. The tumor from the oculomotor and interpeduncular cistern was removed in all except on one side of the case with bilateral tumor extension. The oculomotor nerve palsy demonstrated partial recovery in both cases during the 3-month follow-up. CONCLUSION The pituitary adenoma extending to the oculomotor cistern can be removed under the endoscope. Improvement of oculomotor nerve palsy can be achieved, and further tumor extension into the interpeduncular cistern can be prevented.
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Affiliation(s)
- Masaaki Taniguchi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, Japan
| | - Tomoaki Nakai
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, Japan
| | - Hidehito Kimura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, Japan
| | - Yuichi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, Japan
| | - Yoichi Uozumi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, Japan
| | - Masaaki Kohta
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, Japan
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Chuo-ku, Kobe, Hyogo, Japan
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Zhou X, Alambyan V, Ostergard T, Pace J, Kohen M, Manjila S, Ramos-Estebanez C. Prolonged Intracisternal Papaverine Toxicity: Index Case Description and Proposed Mechanism of Action. World Neurosurg 2017; 109:251-257. [PMID: 29017981 DOI: 10.1016/j.wneu.2017.09.196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 09/27/2017] [Accepted: 09/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Intracisternal papaverine (iPPV) is a vasodilator used for prophylaxis of intraoperative vasospasm during aneurysmal clipping. Postoperative side effects of iPPV include transient cranial nerve palsies, most commonly mydriasis owing to oculomotor nerve involvement, with rapid resolution. METHODS We critically reviewed current literature on the adverse effects of iPPV in aneurysmal surgery with a focus on oculomotor nerve involvement. We also present the index case of prolonged bilateral mydriasis secondary to iPPV irrigation toxicity and its putative underlying mechanism. RESULTS Papaverine toxicity occurs in the setting of its antimuscarinic action and blood-cerebrospinal fluid and blood-brain barrier compromise owing to acute subarachnoid hemorrhage and direct effect of papaverine. Our patient also experienced severe vasospasm and a minor stroke, both contributing to further blood-brain barrier disruption, and relatively acidic pH of the subarachnoid hemorrhage milieu. CONCLUSIONS We propose that these factors perpetuate phase dynamics of papaverine crystals and facilitate a sustained slow release of papaverine within the cisternal system. Were it indicated, 0.3% iPPV would reasonably diminish the risk for neurotoxicity.
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Affiliation(s)
- Xiaofei Zhou
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Vilakshan Alambyan
- Department of Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Thomas Ostergard
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Jonathan Pace
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Maryo Kohen
- Department of Ophthalmology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Sunil Manjila
- Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ciro Ramos-Estebanez
- Department of Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.
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Park HK, Rha HK, Lee KJ, Chough CK, Joo W. Microsurgical Anatomy of the Oculomotor Nerve. Clin Anat 2016; 30:21-31. [DOI: 10.1002/ca.22811] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 11/16/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Hae Kwan Park
- Department of Neurosurgery; Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine; Seoul South Korea
| | - Hyung Keun Rha
- Department of Neurosurgery; Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine; Seoul South Korea
| | - Kyung Jin Lee
- Department of Neurosurgery; Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine; Seoul South Korea
| | - Chung Kee Chough
- Department of Neurosurgery; Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine; Seoul South Korea
| | - Wonil Joo
- Department of Neurosurgery; Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine; Seoul South Korea
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Abstract
The anatomy of the skull base is complex with multiple neurovascular structures in a small space. Understanding all of the intricate relationships begins with understanding the anatomy of the sphenoid bone. The cavernous sinus contains the carotid artery and some of its branches; cranial nerves III, IV, VI, and V1; and transmits venous blood from multiple sources. The anterior skull base extends to the frontal sinus and is important to understand for sinus surgery and sinonasal malignancies. The clivus protects the brainstem and posterior cranial fossa. A thorough appreciation of the anatomy of these various areas allows for endoscopic endonasal approaches to the skull base.
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Affiliation(s)
- Chirag R Patel
- Department of Otolaryngology, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite 500, Pittsburgh, PA 15213, USA; Center for Cranial Base Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite 500, Pittsburgh, PA 15213, USA
| | - Juan C Fernandez-Miranda
- Center for Cranial Base Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite 500, Pittsburgh, PA 15213, USA; Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, PUH B-400, Pittsburgh, PA 15213, USA
| | - Wei-Hsin Wang
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, PUH B-400, Pittsburgh, PA 15213, USA; Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite 500, Pittsburgh, PA 15213, USA; Center for Cranial Base Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite 500, Pittsburgh, PA 15213, USA.
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Tsutsumi S, Miranda JCF, Ono H, Yasumoto Y. The cisternal segments of the oculomotor nerve: a magnetic resonance imaging study. Surg Radiol Anat 2016; 39:323-331. [DOI: 10.1007/s00276-016-1725-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 07/17/2016] [Indexed: 10/21/2022]
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Affiliation(s)
- Atul Goel
- King Edward VII Memorial Hospital and Seth G.S. Medical College, Parel, Mumbai, India
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Hoang N, Tran DK, Herde R, Couldwell GC, Osborn AG, Couldwell WT. Pituitary macroadenomas with oculomotor cistern extension and tracking: implications for surgical management. J Neurosurg 2015; 125:315-22. [PMID: 26566201 DOI: 10.3171/2015.5.jns15107] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Oculomotor cistern extension of pituitary adenomas is an overlooked feature within the literature. In this study, 7 cases of pituitary macroadenoma with oculomotor cistern extension and tracking are highlighted, and the implications of surgical and medical management are discussed. METHODS The records of patients diagnosed with pituitary macroadenomas who underwent resection and in whom preoperative pituitary protocol MRI scans were available for review were retrospectively reviewed. The patient and tumor characteristics were reviewed along with the operative outcomes and complications. RESULTS Seven patients (4.1%) with oculomotor cistern extension and tracking were identified in a cohort of 170 patients with pituitary macroadenoma. The most common presenting symptoms were visual deficit (6 patients; 86%), apoplexy (3 patients; 43%), and oculomotor nerve palsy (3 patients; 43%). Lone oculomotor nerve palsy was seen in 2 patients without apoplexy and 1 patient with an apoplectic event. Gross-total resection was achieved via a microscopic endonasal transsphenoidal approach with or without endoscopic aid to the sella in 14%, near-total resection in 29%, and subtotal resection in 57% of patients in the data set. CONCLUSIONS Pituitary adenoma extension along the oculomotor cistern is uncommon; however, preoperatively recognizing such extension should play an important role in the surgeon's operative considerations and postoperative clinical management because this extension can limit gross-total resection using the transsphenoidal approach alone.
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Affiliation(s)
| | | | - Ryan Herde
- Radiology, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | | | - Anne G Osborn
- Radiology, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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Arachnoid membrane: the first and probably the last piece of the roadmap. Surg Radiol Anat 2014; 37:127-38. [DOI: 10.1007/s00276-014-1361-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 08/12/2014] [Indexed: 10/24/2022]
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Blitz AM, Choudhri AF, Chonka ZD, Ilica AT, Macedo LL, Chhabra A, Gallia GL, Aygun N. Anatomic Considerations, Nomenclature, and Advanced Cross-sectional Imaging Techniques for Visualization of the Cranial Nerve Segments by MR Imaging. Neuroimaging Clin N Am 2014; 24:1-15. [DOI: 10.1016/j.nic.2013.03.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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High-Resolution CISS MR Imaging With and Without Contrast for Evaluation of the Upper Cranial Nerves. Neuroimaging Clin N Am 2014; 24:17-34. [DOI: 10.1016/j.nic.2013.03.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kim MK, Choi HS, Jeun SS, Jung SL, Ahn KJ, Kim BS. Arachnoid cyst in oculomotor cistern. Korean J Radiol 2013; 14:829-31. [PMID: 24043981 PMCID: PMC3772267 DOI: 10.3348/kjr.2013.14.5.829] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 04/15/2013] [Indexed: 11/20/2022] Open
Abstract
Oculomotor cistern is normal anatomic structure that is like an arachnoid-lined cerebrospinal fluid-filled sleeve, containing oculomotor nerve. We report a case of arachnoid cyst in oculomotor cistern, manifesting as oculomotor nerve palsy. The oblique sagittal MRI, parallel to the oculomotor nerve, showed well-defined and enlarged subarachnoid spaces along the course of oculomotor nerve. Simple fenestration was done with immediate regression of symptom. When a disease develops in oculomotor cistern, precise evaluation with proper MRI sequence should be performed to rule out tumorous condition and prevent injury of the oculomotor nerve.
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Affiliation(s)
- Min-Kyun Kim
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 137-701, Korea
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Bae YJ, Kim JH, Choi BS, Jung C, Kim E. Brainstem pathways for horizontal eye movement: pathologic correlation with MR imaging. Radiographics 2013; 33:47-59. [PMID: 23322826 DOI: 10.1148/rg.331125033] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Horizontal eye movements are conducted by the medial rectus and the lateral rectus muscles, which are innervated by the oculomotor nerve (cranial nerve III) and the abducens nerve (cranial nerve VI), respectively. The oculomotor and the abducens nuclei are interconnected by a tract in the brainstem named the medial longitudinal fasciculus (MLF). Through the MLF, the actions of the oculomotor and the abducens nuclei are coordinated, generating conjugate horizontal eye movements. The disorders of horizontal eye movement that are caused by brainstem lesions are classified into three groups: (a) lateral gaze palsy, (b) internuclear ophthalmoplegia, and (c) one-and-a-half syndrome. Lateral gaze palsy is caused by a lesion involving the paramedian pontine reticular formation (PPRF) or the abducens nucleus. Internuclear ophthalmoplegia occurs as a result of a lesion involving the MLF. One-and-a-half syndrome is a combination of lateral gaze palsy and internuclear ophthalmoplegia and is caused by a lesion involving both (a) the ipsilateral PPRF or the ipsilateral abducens nucleus and (b) the ipsilateral MLF. The pathologic lesions depicted on magnetic resonance images were topographically well correlated with the brainstem pathways and each type of horizontal eye movement disorder. Most of the lesions were tiny acute infarctions and were found in the most posterior region of the pons, which corresponded to the location of the brainstem pathways. Therefore, awareness of the brainstem pathways controlling horizontal eye movement is important to avoid missing a small pontine lesion.
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Affiliation(s)
- Yun Jung Bae
- Department of Radiology, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 436-707, Korea
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Abstract
Our purpose was to present 3 cases of perineural tumor spread (PNS) to the oculomotor (CN III) nerve. To our knowledge, PNS to CN III has not been previously reported. In the course of advanced PNS, typically with involvement of the cavernous sinus, tumor may spread in a retrograde fashion to involve CN III in the interpeduncular fossa and can even invade the brainstem.
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Neonatal post-hemorrhagic hydrocephalus resulting in foraminal septae-radiological technique and surgical implications. Childs Nerv Syst 2013; 29:159-62. [PMID: 22996826 DOI: 10.1007/s00381-012-1923-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 09/05/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Intraventricular haemorrhage is the most common cause of hydrocephalus in a pre-term baby and may require surgical intervention depending on severity. CLINICAL CASE This case illustrates foraminal septae as a subtle cause of progressive quadriventricular hydrocephalus in a child born pre-term with a history of grade III intraventricular haemorrhage. The septae within the fourth ventricular exits were clearly demonstrated with 3D-FIESTA (fast imaging employing steady-state acquisition) MRI acquisitions and assisted in differentiation from communicating hydrocephalus. This finding guided the decision to a successful endoscopic third ventriculostomy. CONCLUSION 3D-FIESTA sequence is recommended for investigating children with hydrocephalus secondary to intraventricular haemorrhage due to its diagnostic potential and implications on surgical technique.
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Abstract
The lateral sellar compartment is a complex anatomical structure containing many different elements, any of which can be at the root of a pathological condition. MRI is the examination of choice for this region, and requires the use of specific protocols and systematic examination of each of these elements to produce a suitable diagnosis.
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Affiliation(s)
- A Boulin
- Neuroradiology Department, Hôpital Foch, Suresnes, France.
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Sethi K, Das C. Magnetic Resonance Imaging of the Oculomotor Nerve. Neuroradiol J 2011; 24:444-51. [DOI: 10.1177/197140091102400316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Accepted: 01/03/2011] [Indexed: 11/17/2022] Open
Abstract
Oculomotor/cranial nerve III palsy is caused by numerous etiologies involving the brainstem, subarachnoid space, cavernous sinus or superior orbital fissure or orbit. Magnetic resonance imaging (MRI) is the most suitable neuro-imaging technique in patients with this presentation to rule out a mass, aneurysm or ischemic vasculopathy. A pictorial review of various pathologies affecting the oculomotor nerve is presented along with their MRI morphology.
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Affiliation(s)
- K.S. Sethi
- Diwan Chand Imaging & Research Institute; New Delhi, India
| | - C.J. Das
- Diwan Chand Imaging & Research Institute; New Delhi, India
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Goel A, Shah A. "Interdural" oculomotor neurinoma: report of two surgically treated cases. Acta Neurochir (Wien) 2010; 152:1721-4. [PMID: 20505961 DOI: 10.1007/s00701-010-0690-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Accepted: 05/10/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Dural relationships and their possible implications on surgical treatment of oculomotor nerve neurinomas are discussed on the basis of surgical experience with two cases. MATERIALS AND METHODS We describe two cases with large oculomotor neurinomas that probably arose from the precavernous sinus segment of the nerve. Both tumors were located entirely within the confines of dura or were "interdural." Operating within the limits set and protection afforded by the dura, the tumors could be excised relatively easily and safely. While the third nerve function recovered completely in one patient, the other continued to have complete third nerve palsy. The duration of follow-up in two cases was 52 and 24 months. RESULTS AND CONCLUSIONS Even the intracranial component of large oculomotor neurinoma can be covered entirely by dura. Understanding of the dural relationship can assist in planning and conduct of surgery.
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Affiliation(s)
- Atul Goel
- Department of Neurosurgery, King Edward VII Memorial Hospital and Seth G.S. Medical College, Parel, Mumbai, India.
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Hodaie M, Quan J, Chen DQ. In Vivo Visualization of Cranial Nerve Pathways in Humans Using Diffusion-Based Tractography. Neurosurgery 2010; 66:788-95; discussion 795-6. [DOI: 10.1227/01.neu.0000367613.09324.da] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Diffusion-based tractography has emerged as a powerful technique for 3-dimensional tract reconstruction and imaging of white matter fibers; however, tractography of the cranial nerves has not been well studied. In particular, the feasibility of tractography of the individual cranial nerves has not been previously assessed.
METHODS
3-Tesla magnetic resonance imaging scans, including anatomic magnetic resonance images and diffusion tensor images, were used for this study. Tractography of the cranial nerves was performed using 3D Slicer software. The reconstructed 3-dimensional tracts were overlaid onto anatomic images for determination of location and course of intracranial fibers.
RESULTS
Detailed tractography of the cranial nerves was obtained, although not all cranial nerves were imaged with similar anatomic fidelity. Some tracts were imaged in great detail (cranial nerves II, III, and V). Tractography of the optic apparatus allowed tracing from the optic nerve to the occipital lobe, including Meyer's loop. Trigeminal tractography allowed visualization of the gasserian ganglion as well as postganglionic fibers. Tractography of cranial nerve III shows the course of the fibers through the midbrain. Lower cranial nerves (cranial nerves IX, XI, and XII) could not be imaged well.
CONCLUSION
Tractography of the cranial nerves is feasible, although technical improvements are necessary to improve the tract reconstruction of the lower cranial nerves. Detailed assessment of anatomy and the ability of overlaying the tracts onto anatomic magnetic resonance imaging scans is essential, particularly in the posterior fossa, to ensure that the tracts have been reconstructed with anatomic fidelity.
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Affiliation(s)
- Mojgan Hodaie
- Division of Neurosurgery, University of Toronto and Toronto Western Hospital, Toronto, Canada
| | - Jessica Quan
- Faculty of Medicine, Queen's University, Kingston, Canada
| | - David Qixiang Chen
- Division of Neurosurgery, University of Toronto and Toronto Western Hospital, Toronto, Canada
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Dinçer A, Kohan S, Ozek MM. Is all "communicating" hydrocephalus really communicating? Prospective study on the value of 3D-constructive interference in steady state sequence at 3T. AJNR Am J Neuroradiol 2009; 30:1898-906. [PMID: 19643921 DOI: 10.3174/ajnr.a1726] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE 3D-constructive interference in steady state (3D-CISS) sequence has been used to assess the CSF pathways. The aim of this study was to investigate the additive value of 3D-CISS compared with conventional sequences in the diagnosis of obstructive membranes in hydrocephalus. MATERIALS AND METHODS A total of 134 patients with hydrocephalus underwent MR imaging examination with a 3T unit consisting of turbo spin-echo, 3D-CISS, and cine phase-contrast (cine PC) sequences. 3D-CISS was used to assess obstructive membranes in CSF pathways compared with other sequences. Cine PC, follow-up imaging, and surgical findings were used to confirm obstructive membranes. RESULTS Comparing the number of noncommunicating cases by using the conventional and 3D-CISS images, we found 26 new cases (19.4%) of 134 cases that were previously misdiagnosed as communicating hydrocephalus by conventional images. 3D-CISS sequence identified obstructive membranes invisible in other sequences, which facilitated selection of neuroendoscopy in the treatment of 31 patients (23.1%) in total who would have been otherwise treated with shunt insertion. These patients included 26 newly diagnosed noncommunicating cases after demonstration of intraventricular and/or fourth ventricular outlet membranes and 5 cases of communicating hydrocephalus with obstructing cisternal membranes. There were obstructions of the foramina of Luschka in 22 of 26 newly found noncommunicating cases. CONCLUSIONS Conventional sequences are insensitive to obstructive membranes in CSF pathways, especially in the fourth ventricular exit foramina and the basal cisterns. 3D-CISS sequence, revealing these obstructive membranes, can alter patient treatment and prognosis.
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Affiliation(s)
- A Dinçer
- Acibadem University, School of Medicine, Department of Radiology, Istanbul, Turkey.
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Hermier M, Leal P, Salaris S, Froment JC, Sindou M. Imagerie anatomique des nerfs crâniens. Neurochirurgie 2009; 55:162-73. [DOI: 10.1016/j.neuchi.2009.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Accepted: 01/16/2009] [Indexed: 11/17/2022]
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