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Donofrio CA, Corrivetti F, Riccio L, Corvino S, Dallan I, Fioravanti A, de Notaris M. Combined Endoscopic Endonasal Transclival and Contralateral Transmaxillary Approach to the Petrous Apex and the Petroclival Synchondrosis: Working "Around the Corner" of the Internal Carotid Artery-Quantitative Anatomical Study and Clinical Applications. J Clin Med 2024; 13:2713. [PMID: 38731242 PMCID: PMC11084429 DOI: 10.3390/jcm13092713] [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: 03/27/2024] [Revised: 04/30/2024] [Accepted: 05/01/2024] [Indexed: 05/13/2024] Open
Abstract
The endoscopic contralateral transmaxillary (CTM) approach has been proposed as a potential route to widen the corridor posterolateral to the internal carotid artery (ICA). In this study, we first refined the surgical technique of a combined multiportal endoscopic endonasal transclival (EETC) and CTM approach to the petrous apex (PA) and petroclival synchondrosis (PCS) in the dissection laboratory, and then validated its applications in a preliminary surgical series. The combined EETC and CTM approach was performed on three cadaver specimens based on four surgical steps: (1) the nasal, (2) the clival, (3) the maxillary and (4) the petrosal phases. The CTM provided a "head-on trajectory" to the PA and PCS and a short distance to the surgical field considerably furthering surgical maneuverability. The best operative set-up was achieved by introducing angled optics via the endonasal route and operative instruments via the transmaxillary corridor exploiting the advantages of a non-coaxial multiportal surgery. Clinical applications of the combined EETC and CTM approach were reported in three cases, a clival chordoma and two giant pituitary adenomas. The present translational study explores the safety and feasibility of a combined multiportal EETC and CTM approach to access the petroclival region though different corridors.
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Affiliation(s)
- Carmine Antonio Donofrio
- Department of Neurosurgery, ASST Cremona, 2610 Cremona, Italy; (C.A.D.); (L.R.); (A.F.)
- Division of Biology and Genetics, Department of Molecular and Translational Medicine, Faculty of Medicine, University of Brescia, 25121 Brescia, Italy
| | - Francesco Corrivetti
- Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, 84125 Salerno, Italy; (S.C.); (M.d.N.)
| | - Lucia Riccio
- Department of Neurosurgery, ASST Cremona, 2610 Cremona, Italy; (C.A.D.); (L.R.); (A.F.)
| | - Sergio Corvino
- Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, 84125 Salerno, Italy; (S.C.); (M.d.N.)
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy
| | - Iacopo Dallan
- Otorhinolaryngology, Audiology and Phoniatrics Operative Unit, Department of Surgical, Medical, Molecular Pathology and Emergency Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, 56124 Pisa, Italy
| | - Antonio Fioravanti
- Department of Neurosurgery, ASST Cremona, 2610 Cremona, Italy; (C.A.D.); (L.R.); (A.F.)
| | - Matteo de Notaris
- Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, 84125 Salerno, Italy; (S.C.); (M.d.N.)
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, School of Medicine, University of Naples “Federico II”, 80131 Naples, Italy
- Otorhinolaryngology, Audiology and Phoniatrics Operative Unit, Department of Surgical, Medical, Molecular Pathology and Emergency Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, 56124 Pisa, Italy
- Department of Neurosurgery, San Luca Hospital, Vallo della Lucania, 84078 Salerno, Italy
- Unit of Neurosurgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, University of Salerno, 84131 Salerno, Italy
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Troude L, Al-Shabibi T, Baucher G, Roche PH. The trans-sylvian trans-petrosal "half & half" approach-a how I do it. Acta Neurochir (Wien) 2024; 166:158. [PMID: 38558198 DOI: 10.1007/s00701-024-06056-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/19/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Petroclival meningiomas are one of the most challenging tumors to be operated in the realm of neurosurgery. Many approaches have been developed over the years. METHOD The authors describe the Half & Half (H&H) approach whose main indication is petroclival meningiomas with suprasellar extension. The part of the tumor located above CN III and in the retrochiasmatic space is addressed through a trans-sylvian, while the petroclival portion is through an extradural anterior petrosectomy approach. The wide surgical corridor given by this approach allows extensive tumor resection while avoiding the risk associated with the manipulation of intracavernous neurovascular structures. CONCLUSION The H&H approach is an effective strategy to maximize the safe resection of petroclival meningiomas.
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Affiliation(s)
- Lucas Troude
- Department of Neurosurgery, North University Hospital, APHM, 13015, Marseille, France.
| | - Talal Al-Shabibi
- Department of Neurosurgery, North University Hospital, APHM, 13015, Marseille, France
| | - Guillaume Baucher
- Department of Neurosurgery, North University Hospital, APHM, 13015, Marseille, France
| | - Pierre-Hugues Roche
- Department of Neurosurgery, North University Hospital, APHM, 13015, Marseille, France
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Coutinho da Silva MB, Hernández Hernández V, Gupta P, Lavinsky J, Zenonos GA, Wang EW, Snyderman CH, Gardner PA. Anteromedial Petrous (Gardner's) Triangle: Surgical Anatomy and Relevance for Endoscopic Endonasal Approach to the Petrous Apex and Petroclival Region. Oper Neurosurg (Hagerstown) 2024; 26:330-340. [PMID: 37856762 DOI: 10.1227/ons.0000000000000959] [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: 02/25/2023] [Accepted: 08/13/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Triangular corridors have been used as reliable surgical entry points for open transcranial approaches to the petrous apex (PA) and petroclival region (PCR). The endoscopic endonasal approaches have grown rapidly in the last decade, and the indications have advanced. The knowledge of accurate and reliable anatomic landmarks through endoscopic endonasal route is essential and remain to be established. The purpose of this study was to describe the feasibility and surgical exposure of the anteromedial petrous (Gardner's) triangle as a novel corridor to the PA and PCR. METHODS Five anatomic specimens were dissected. The PA and PCR were accessed through endoscopic endonasal approaches and contralateral transmaxillary approach. The limits of the anteromedial petrous (Gardner's) triangle were identified and dissected and associated measurements performed. RESULTS The dissection was divided into 6 steps. The limits of the anteromedial petrous (Gardner's) triangle were identified and defined by the paraclival internal carotid artery anterolaterally, the abducens nerve posteromedially, and the petroclival synchondrosis inferiorly. Three lines were established following the limits of the triangle. The mean distance of the anterolateral limit was 10.03 mm (SD = 0.94), of the posteromedial limit was 20.06 mm (SD = 2.90), and of the inferior limit was 17.99 mm (SD = 2.99). The mean area was 87.56 mm 2 (SD = 20.06). The 3 anatomic landmarks with a critical role to safely define the triangle were the pterygosphenoidal fissure, the petrosal process of the sphenoid bone, and the petroclival synchondrosis. CONCLUSION The anteromedial (Gardner's) triangle is a well-defined bone corridor which provides access to the entire petrous bone and petroclival junction through endoscopic endonasal route. Regardless of the anatomic variations or tumor location, the landmarks of the abducens nerve, paraclival internal carotid artery, and petroclival synchondrosis are key for understanding lateral access to tumors extending from the clivus.
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Affiliation(s)
- Martin B Coutinho da Silva
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
- Postgraduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre , Rio Grande do Sul , Brazil
| | - Vanessa Hernández Hernández
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Prakash Gupta
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Joel Lavinsky
- Postgraduate Program in Medicine: Surgical Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre , Rio Grande do Sul , Brazil
| | - Georgios A Zenonos
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
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Méndez Rosito D, Borrayo-Dorado S, Zorrilla-Madera E, Sánchez-Gallardo JF, Gallardo-Ceja D, Ríos FJ, Cárdenas Y, Palmisciano P, Forbes JA, Abdala-Vargas NJ. The M-Point A Novel Landmark in Middle Fossa Surgery: A Cadaveric Morphometric Study. World Neurosurg 2024; 181:e67-e74. [PMID: 37385439 DOI: 10.1016/j.wneu.2023.06.098] [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: 02/13/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND The arcuate eminence (AE) is an anatomically consistent bony protrusion located on the upper surface of the petrous bone that has been previously studied as a reference for lateral skull base approaches. There is a paucity of information in the neurosurgical literature seeking to improve the safety of the extended middle cranial fossa (MCF) approach using detailed morphometric analysis of the AE. OBJECTIVE To evaluate the use of the AE as an anatomical landmark to help with early identification of the internal acoustic canal (IAC) in MCF approaches by means of a cadaveric study, using a new morphometric reference termed the "M-point." METHODS A total of 40 dry temporal bones and 2 formalin-preserved, latex-injected cadaveric heads were used. The M-point was established as a new anatomic reference by identifying the intersection of a line perpendicular to the alignment of the petrous ridge (PR), originating from the midpoint of the AE, with the PR itself. Subsequent anatomical measurements were performed to measure the distance between M-point and IAC. Additional distances, including PR length and the anteroposterior and lateral AE surfaces, were also measured. RESULTS The mean distance between the M-point and the center of the IAC was 14.9 mm (SD ± 2.09), offering a safe drilling area during an MCF approach. CONCLUSIONS This study provides novel information on identification of a new anatomic reference point known as the M-point that that can be used to improve early surgical identification of the IAC.
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Affiliation(s)
- Diego Méndez Rosito
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico.
| | - Sheila Borrayo-Dorado
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Elias Zorrilla-Madera
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | | | - David Gallardo-Ceja
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Francisco J Ríos
- Department of Anatomy, Escuela Superior de Medicina, IPN, Mexico City, Mexico
| | - Yolanda Cárdenas
- Department of Anatomy, Escuela Superior de Medicina, IPN, Mexico City, Mexico
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan A Forbes
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nadin J Abdala-Vargas
- Laboratorio de Base de Cráneo, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico; Department of Neurological Surgery, Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital de San José, Bogotá, Colombia
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Yamakami I, Kubota S, Higuchi Y, Horiguchi K, Matsuda T. Cyst-to-Mastoid Antrum Diversion as an Alternate Pathway for Management of Small Symptomatic Petrous Apex Cholesterol Granuloma Without Anteromedial Expansion Using an Extradural Middle Fossa Approach: A Technical Case Report. Oper Neurosurg (Hagerstown) 2023; 24:e126-e129. [PMID: 36637323 DOI: 10.1227/ons.0000000000000473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/19/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Cholesterol granuloma (CG) is the most common petrous apex (PA) cystic lesion. Posterolateral expansion of a PA CG (PACG) compresses the internal auditory canal (IAC), leading to vestibulocochlear (VC) and facial nerve dysfunction. Even small, symptomatic PACGs are managed surgically. The preferred strategy is not complete removal, but drainage and aeration. PACG with anteromedial expansion using an endoscopic endonasal approach provides natural drainage into the nasal sinus without risking VC and facial dysfunction. Endoscopic endonasal approach is inappropriate for small PACGs without anteromedial expansion because of potential damage to the petrous internal carotid artery. Small PACGs without anteromedial expansion are managed using extradural middle fossa (EMF) approach, which lacks a natural drainage pathway, thus necessitating an artificial drainage pathway for PACG aeration to prevent recurrence. We introduced EMF approach for CG decompression and cyst-to-mastoid antrum (MA) diversion for managing small, symptomatic PACGs without anteromedial expansion. CLINICAL PRESENTATION A 48-year-old woman presented with headache, vertigo, tinnitus, and left hemifacial spasm with preserved hearing because of IAC compression caused by a small PACG without anteromedial expansion. Using the EMF approach, the CG and IAC were safely decompressed. Effective and long-standing artificial drainage for CG aeration was established by anterior petrosectomy and silicone tubing from the CG into the MA. Surgery resolved the symptoms, which have not recurred in 3 years. CONCLUSION Granuloma decompression and cyst-to-MA diversion using silicone tubing using the EMF approach is a safe and effective surgical management for small, symptomatic PACG without anteromedial expansion.
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Affiliation(s)
- Iwao Yamakami
- Neurosurgery, Seikei-kai Chiba Medical Center, Chuo-ku, Chiba, Japan
| | - Shunsuke Kubota
- Neurosurgery, Seikei-kai Chiba Medical Center, Chuo-ku, Chiba, Japan
| | - Yoshinori Higuchi
- Neurosurgery Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Kentaro Horiguchi
- Neurosurgery Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Tatsuma Matsuda
- Neurosurgery Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
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6
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Xie T, Wang Y, Zhang X, Shao N, Lu W, Yang Q, Qu C, Li C, Liu T, Liu S, Zhu W. Endoscopic Far-Lateral Supracerebellar Infratentorial Approach for Petroclival Region Meningioma: Surgical Technique and Clinical Experience. Oper Neurosurg (Hagerstown) 2022; 22:290-297. [PMID: 35315837 DOI: 10.1227/ons.0000000000000126] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 11/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The management of petroclival region meningioma remains the ultimate achievement in neurosurgery, because of the formidable technical challenges involved. OBJECTIVE To describe the technique and feasibility of the purely endoscopic far-lateral supracerebellar infratentorial approach (EF-SCITA) for the treatment of petroclival region meningiomas. METHODS We reviewed the clinical data of 10 consecutive cases of petroclival region meningiomas treated with the EF-SCITA from August 2018 to August 2020. The clinical outcomes were analyzed. The patient was placed in the lateral position, and then, a "C" shaped incision and craniotomy with exposed sigmoid and transverse sinuses were performed. With the endoscopic holder, endoscopic procedures were performed using standard 2-hand microsurgical techniques. Whether the tentorium or Meckel cave was handled depended on the tumor extension. RESULTS The mean diameter was 45 × 25 mm. Dizziness and headache were the main symptoms. All 10 patients achieved gross total or subtotal resection (Petroclival Meningioma Grade I-III) with good neurological outcomes. The EF-SCITA provides satisfactory, direct exposure to the petroclival region. Cranial nerve deficits are the main postoperative complications. Two patients had a trochlear nerve injury, 3 patients had transient facial paralysis, and 2 patients had oculomotor paralysis (1 total and 1 incomplete), but both of them recovered during the follow-up period. One patient experienced an ipsilateral superior cerebellar artery infarction, and another patient had transient hemiparesis. CONCLUSION The EF-SCITA is effective for most petroclival region meningiomas, except for the cavernous sinus type. This approach simplifies craniotomy procedures, omits burdensome petrosectomy, and avoids crossing posterior neurovascular structures.
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Affiliation(s)
- Tao Xie
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Cancer Center, Shanghai Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yushe Wang
- Department of Neurosurgery, Henan Provincial Peoples Hospital, Zhengzhou, Henan Province, China
| | - Xiaobiao Zhang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Cancer Center, Shanghai Zhongshan Hospital, Fudan University, Shanghai, China.,Digital Medical Research Center, Fudan University, Shanghai, China
| | - Naiyuan Shao
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu Province, China
| | - Weicheng Lu
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Qiaoqiao Yang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chenghui Qu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chen Li
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tengfei Liu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shuang Liu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei Zhu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
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Loymak T, Belykh E, Abramov I, Tungsanga S, Sarris CE, Little AS, Preul MC. Comparative Analysis of Surgical Exposure among Endoscopic Endonasal Approaches to Petrosectomy: An Experimental Study in Cadavers. J Neurol Surg B Skull Base 2022; 83:526-535. [PMID: 36097500 PMCID: PMC9462962 DOI: 10.1055/s-0041-1741067] [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: 01/19/2021] [Accepted: 11/12/2021] [Indexed: 01/16/2023] Open
Abstract
Objectives Endoscopic endonasal approaches (EEAs) for petrosectomies are evolving to reduce perioperative brain injuries and complications. Surgical terminology, techniques, landmarks, advantages, and limitations of these approaches remain ill defined. We quantitatively analyzed the anatomical relationships and differences between EEA exposures for medial, inferior, and inferomedial petrosectomies. Design This study presents anatomical dissection and quantitative analysis. Setting Cadaveric heads were used for dissection. EEAs were performed using the medial petrosectomy (MP), the inferior petrosectomy (IP), and the inferomedial petrosectomy (IMP) techniques. Participants Six cadaver heads (12 sides, total) were dissected; each technique was performed on four sides. Main Outcomes and Measures Outcomes included the area of exposure, visible distances, angles of attack, and bone resection volume. Results The IMP technique provided a greater area of exposure ( p < 0.01) and bone resection volume ( p < 0.01) when compared with the MP and IP techniques. The IMP technique had a longer working length of the abducens nerve (cranial nerve [CN] VI) than the MP technique ( p < 0.01). The IMP technique demonstrated higher angles of attack to specific neurovascular structures when compared with the MP (midpons [ p = 0.04], anterior inferior cerebellar artery [ p < 0.01], proximal part of the cisternal CN VI segment [ p = 0.02]) and IP (flocculus [ p = 0.02] and the proximal [ p = 0.02] and distal parts [ p = 0.02] of the CN VII/VIII complex) techniques. Conclusion Each of these approaches offers varying degrees of access to the petroclival region, and the surgical approach should be appropriately tailored to the pathology. Overall, the IMP technique provides greater EEA surgical exposure to vital neurovascular structures than the MP and the IP techniques.
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Affiliation(s)
- Thanapong Loymak
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Irakliy Abramov
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Somkanya Tungsanga
- Division of Nephrology, Department of Internal Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Christina E. Sarris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Andrew S. Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark C. Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona,Address for correspondence Mark C. Preul, MD c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center350 West Thomas Road, Phoenix, Arizona 85013
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Xie HM, Richard SA, Lan Z. A petroclival glioma mimicking trigeminal schwannoma: A case report. Medicine (Baltimore) 2021; 100:e27792. [PMID: 34797306 PMCID: PMC8601354 DOI: 10.1097/md.0000000000027792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/29/2021] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Glioma in the petroclival region is very rare. Also, very few cases of primary gliomas have been reported to have radiographic as well as intraoperative features of extra-axial lesions resulting in diagnostic dilemma in the literature. We present a rare case of petroclival glioma mimicking trigeminal schwannoma in a young female. PATIENT CONCERNS We present a 21-years old female with a 3-month history of pain in the right eye with no visual impairment. Cranial nerves examination revealed mild deficits in the trigeminal nerve, facial nerve, auditory nerve, oculomotor as well as the trochlear nerve. DIAGNOSES Magnetic resonance imaging detected an extra-axial mass with mixed signal intensities in the right petroclivus area. Immunohistochemical established glioma with world health organization (WHO) grade II. INTERVENTIONS The lesion was resected via 2 successive operations in 6 months interval. The patient was further treated with radiotherapy and post-radiotherapy temozolamide. OUTCOMES Two years follow-up revealed no recurrence of the lesions and she is well. Nevertheless, he is still being followed diligently to uncover any recurrence. LESSONS The extra-axial nature as well as petroclival location of the glioma makes our case very unique and very rare. The imaging characteristics were very extraordinary for a glioma which resulted in diagnostic dilemma. Thus, the definitive diagnosis was based on the histopathological evaluation of the excised tumor.
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Affiliation(s)
- Hui-Min Xie
- Department of Radiology, West China Hospital, Sichuan University, 37 Guo Xue Xiang Road, Chengdu, Sichuan, PR China
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Road, Chengdu, Sichuan, PR China
- Department of Medicine, Princefield University, P. O. Box MA 128, Ho-Volta Region, Ghana, West Africa
| | - Zhigang Lan
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Road, Chengdu, Sichuan, PR China
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Use of Neuroanatomic Knowledge and Neuronavigation System for a Safe Anterior Petrosectomy. Brain Sci 2021; 11:brainsci11040488. [PMID: 33921434 PMCID: PMC8069204 DOI: 10.3390/brainsci11040488] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/02/2021] [Accepted: 04/09/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction: The petroclival region is among the most challenging anatomical areas to deal with in skull base surgery. Drilling of the anterior part of the petrous bone during the anterior transpetrosal approach involves the risk of injury of the cochlea, superior semicircular canal, internal carotid artery, and internal auditory canal. A thorough understanding of the microneurosurgical anatomy of this region is mandatory to execute the transpetrosal approaches, decreasing the risk of complications. The aim of this study is to describe the anatomical structures of the petroclival region, highlighting the importance of neuronavigation for safe performance of the anterior transpetrosal approach. Methods: Three adult cadaveric human heads were formalin-fixed and injected with colored silicone. They underwent an axial 1 mm slab CT scan, which was used for neuronavigation during the surgical approaches. The anterior petrosectomy was performed with the aid of neuronavigation during the drilling of the petrous bone. The surgical management of a patient harboring a petroclival meningioma, operated on using an anterior transpetrosal approach, was reported as an illustrative case. Results: The anterior petrosectomy was completed accurately with wide exposure of the surgical target without injuring the cochlea and other structures in all three cadaveric specimens. In the surgical case, no approach-related complications occurred, and a gross total resection of the tumor was achieved. Conclusions: Deep knowledge of the location and relationships of the vital elements located within the temporal bone, along with the use of neuronavigation, are the key aspects to perform the anterior transpetrosal approach safely, reducing the risk of complications.
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Mangussi-Gomes J, Alves-Belo JT, Truong HQ, Nogueira GF, Wang EW, Fernandez-Miranda JC, Gardner PA, Snyderman CH. Anatomical Limits of the Endoscopic Contralateral Transmaxillary Approach to the Petrous Apex and Petroclival Region. Skull Base Surg 2020; 83:44-52. [DOI: 10.1055/s-0040-1716693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
Abstract
Abstract
Objectives This study aimed to establish the anatomical landmarks for performing a contralateral transmaxillary approach (CTM) to the petrous apex (PA) and petroclival region (PCR), and to compare CTM with a purely endoscopic endonasal approach (EEA).
Design EEA and CTM to the PA and PCR were performed bilaterally in eight human anatomical specimens. Surgical techniques and anatomical landmarks were described, and EEA was compared with CTM with respect to ability to reach the contralateral internal acoustic canal (IAC). Computed tomographic scans of 25 cadaveric heads were analyzed and the “angle” and “reach” of CTM and EEA were measured.
Results Entry to the PA via a medial approach was limited by (1) abducens nerve superiorly, (2) internal carotid artery (ICA) laterally, and (3) petroclival synchondrosis inferiorly (Gardner's triangle). With CTM, it was possible to reach the contralateral IAC bilaterally in all specimens dissected, without dissection of the ipsilateral ICAs, pterygopalatine fossae, and Eustachian tubes. Without CTM, reaching the contralateral IAC was possible only if: (1) angled endoscopes and instruments were employed or (2) the pterygopalatine fossa was dissected with mobilization of the ICA and resection of the Eustachian tube. The average “angle” and “reach” advantages for CTM were 25.6-degree greater angle of approach behind the petrous ICA and 1.4-cm more lateral reach.
Conclusion The techniques and anatomical landmarks for CTM to the PA and PCR are described. Compared with a purely EEA, the CTM provides significant “angle” and “reach” advantages for the PA and PCR.
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Affiliation(s)
- João Mangussi-Gomes
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - João T. Alves-Belo
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Huy Q. Truong
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | | | - Eric W. Wang
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Juan C. Fernandez-Miranda
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Paul A. Gardner
- Surgical Neuroanatomy Lab, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
| | - Carl H. Snyderman
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States
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11
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Li KL, Agarwal V, Moskowitz HS, Abuzeid WM. Surgical approaches to the petrous apex. World J Otorhinolaryngol Head Neck Surg 2020; 6:106-114. [PMID: 32596655 PMCID: PMC7296478 DOI: 10.1016/j.wjorl.2019.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 11/27/2019] [Indexed: 11/18/2022] Open
Abstract
The petrous apex is a difficult to reach surgical area due to its deep position in the skull base and many vital surrounding structures. Petrous apex pathology ranges from extradural cholesterol granulomas, cholesteatomas, asymmetric pneumatization, and osteomyelitis to intradural meningiomas and schwannomas. Certain lesions, such as cholesterol granulomas, can be managed with drainage while neoplastic lesions must be completely resected. Surgical options use open, endoscopic, and combined techniques and are categorized into anterior, lateral, and posterior approaches. The choice of approach is determined by the nature of the pathology and location relative to vital structures and extension into surrounding structures and requires thorough preoperative evaluation and discussion of surgical goals with the patient. The purpose of this state-of-the-art review is to discuss the most commonly used surgical approaches to the petrous apex, and the anatomy on which these approaches are based.
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Affiliation(s)
- Kevin L Li
- Department of Otorhinolaryngology - Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Vijay Agarwal
- Department of Neurosurgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Howard S Moskowitz
- Department of Otorhinolaryngology - Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Waleed M Abuzeid
- Department of Otorhinolaryngology - Head and Neck Surgery, Albert Einstein College of Medicine, Bronx, NY, USA
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12
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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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13
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Nicosia L, Pietro SD, Catapano M, Spadarella G, Sammut L, Cannataci C, Resta F, Reganati P. Petroclival meningiomas: radiological features essential for surgeons. Ecancermedicalscience 2019; 13:907. [PMID: 31123490 PMCID: PMC6445566 DOI: 10.3332/ecancer.2019.907] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Indexed: 12/23/2022] Open
Abstract
Petroclival meningiomas (PCMs) have always been a challenge for surgeons because of their difficult anatomical location. The role of radiology in providing precise indications regarding the tumour site and aggressiveness plays a major part in guiding the subsequent therapeutic process. The purpose of this review is to provide a set of the main radiological features helpful in the management of PCMs towards the most correct therapeutic approach. We aim to offer a radiological overview to allow the patient to be directed to surgery with the least possible risk of complications.
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Affiliation(s)
- Luca Nicosia
- Breast Radiology Department, European Institute of Oncology, 2014, Via G Ripamonti 435, Milano, Italy.,Luca Nicosia and Salvatore Di Pietro contributed equally and share first-authorship
| | - Salvatore Di Pietro
- Breast Radiology Department, European Institute of Oncology, 2014, Via G Ripamonti 435, Milano, Italy.,Luca Nicosia and Salvatore Di Pietro contributed equally and share first-authorship
| | - Michele Catapano
- Breast Radiology Department, European Institute of Oncology, 2014, Via G Ripamonti 435, Milano, Italy
| | - Gaia Spadarella
- Breast Radiology Department, European Institute of Oncology, 2014, Via G Ripamonti 435, Milano, Italy
| | - Lara Sammut
- Medical Imaging Department, Mater Dei Hospital, Triq Dun Karm, MSD 2090 Msida, Malta
| | - Christine Cannataci
- Medical Imaging Department, Mater Dei Hospital, Triq Dun Karm, MSD 2090 Msida, Malta
| | - Federico Resta
- Neuroradiology Unit, San Giuseppe Hospital, Milano Via San Vittore 12, 20123 Milano, Italy
| | - Paolo Reganati
- Neuroradiology Unit, San Giuseppe Hospital, Milano Via San Vittore 12, 20123 Milano, Italy
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14
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Bernard F, Troude L, Isnard S, Lemée JM, Terrier LM, François P, Velut S, Gay E, Fournier HD, Roche PH. Long term surgical results of 154 petroclival meningiomas: A retrospective multicenter study. Neurochirurgie 2019; 65:55-62. [PMID: 31104846 DOI: 10.1016/j.neuchi.2019.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 02/02/2019] [Accepted: 02/03/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Outcomes of petroclival meningiomas (PCM) (morbidity, permanent cranial nerves deficit, tumor removal and recurrence) are inconsistent in the literature, making it a challenge to predict surgical morbidity. METHODS A multicenter study of patients with PCMs larger than 2.5cm between 1984 and 2017 was conducted. The authors retrospectively reviewed the patients' medical records, imaging studies and pathology reports to analyze presentation, surgical approach, neurological outcomes, complications, recurrence rates and predictive factors. RESULTS There were 154 patients. The follow-up was 76.8 months on average (range 8-380 months). Gross total resection (GTR) was achieved in 40 (26.0%) patients, subtotal resection (STR) in 101 (65.6%), and partial resection in 13 (8.3%). Six (2.6%) perioperative deaths occurred. The 5-year, 10-year and 15-year progression-free survival (PFS) of GTR and STR with radiation therapy (RT) was similar (100%, 90% and 75%). PFS of STR without adjuvant radiation was associated with progression in 71%, 51% and 31%, respectively. Anterior petrosectomy and combined petrosectomy were associated with higher postoperative CN V and CN VI deficits compared to the retrosigmoid approach. The latter had a significantly higher risk of CN VII, CN VIII and LCN deficit. Temporal lobe dysfunction (seizure and aphasia) were significantly associated with the anterior petrosectomy approach. CONCLUSIONS Our study shows that optimal subtotal resection of PCMs associated with postoperative RT or stereotactic radiosurgery results in long-term tumor control to equivalent radical surgery. Case selection and appropriate intraoperative judgement are required to reduce the morbidity.
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Affiliation(s)
- F Bernard
- Department of Neurosurgery, CHU Anger, 49100 Angers, France.
| | - L Troude
- Department of Neurosurgery, CHU APHM-Hopital Nord, 13015 Marseille, France.
| | - S Isnard
- Department of Neurosurgery, CHRU de Grenoble, 38000 Grenoble, France.
| | - J-M Lemée
- Department of Neurosurgery, CHU Anger, 49100 Angers, France.
| | - L M Terrier
- Department of Neurosurgery, CHRU de Tours, 37044 Tours, France.
| | - P François
- Department of Neurosurgery, CHRU de Tours, 37044 Tours, France.
| | - S Velut
- Department of Neurosurgery, CHRU de Tours, 37044 Tours, France.
| | - E Gay
- Department of Neurosurgery, CHRU de Grenoble, 38000 Grenoble, France.
| | - H-D Fournier
- Department of Neurosurgery, CHU Anger, 49100 Angers, France.
| | - P-H Roche
- Department of Neurosurgery, CHU APHM-Hopital Nord, 13015 Marseille, France.
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15
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Spiessberger A, Baumann F, Stauffer A, Marbacher S, Kothbauer KF, Fandino J, Moriggl B. Extended exposure of the petroclival junction: The combined anterior transpetrosal and subtemporal/transcavernous approach. Surg Neurol Int 2019; 9:259. [PMID: 30687570 PMCID: PMC6322168 DOI: 10.4103/sni.sni_298_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 12/02/2018] [Indexed: 11/17/2022] Open
Abstract
Background: The combined anterior transpetrosal and subtemporal/transcavernous (atsta) approach to the petroclival junction provides a wide exposure facilitating resection of large tumor lesions such as petroclival mengiomas, chondrosarcomas, or chordomas. In this article we provide technical instructions on the approach with anatomical consideration and a literature review of previous applications of this approach. Methods: The combined approach was performed in two cadaveric specimen and relevant anatomical aspects were studied. Additionally, the authors performed a review of the literature focusing on indications, neurologic outcome, and complications associated with the technique. Results: A combined atsta approach offers a wide exposure of the crus cerebrum, pons, basal temporal lobe, cranial nerves III to VII/VIII, posterior cerebral artery (PCA), superior cerebellar artery (SCA), basilar artery (BA), anterior inferior cerebellar artery (AICA), and posterior communicating artery (Pcom). It has been successfully applied with acceptable morbidity and mortality rates, mainly for (spheno-) petroclival meningiomas. Conclusion: The combined approach studied here is a useful skull base approach to the petroclival junction and can be applied to treat large or complex pathologies of the region. Detailed anatomical knowledge is essential.
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Affiliation(s)
| | - Fabian Baumann
- Department of Neurosurgery, Luzerner Kantonsspital, Spitalstrasse, 6000 Luzern/Switzerland
| | - Alexandra Stauffer
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 1, 5001 Aarau/Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 1, 5001 Aarau/Switzerland
| | - Karl F Kothbauer
- Department of Neurosurgery, Luzerner Kantonsspital, Spitalstrasse, 6000 Luzern/Switzerland.,Universität Basel, Petersplatz 1, 4001 Basel/Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 1, 5001 Aarau/Switzerland
| | - Bernhard Moriggl
- Department of Anatomy, Histology and Embryology, Medical University of Innsbruck (MUI), 6020 Innsbruck/Austria
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16
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Tawfik-Helika M, Mertens P, Ribas G, Cusimano MD, Catala M, Kirollos R, Jacquesson T. Understanding Anatomy of the Petrous Pyramid-A New Compartmental Approach. World Neurosurg 2019; 124:e65-e80. [PMID: 30620892 DOI: 10.1016/j.wneu.2018.11.234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 11/24/2018] [Accepted: 11/26/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Learning surgical anatomy of the petrous pyramid can be a challenge, especially in the beginning of the training process. Providing an easier, holistic approach can be of help to everyone with interest in learning and teaching skull base anatomy. We present the complex organization of petrous pyramid anatomy using a new compartmental approach that is simple to understand and remember. METHODS The surfaces of the petrous pyramid of two temporal bones were examined; and the contents of the petrous pyramid of 8 temporal bones were exposed through progressive drilling of the superior surface. RESULTS The petrous pyramid is made up of a bony container, and its contents were grouped into 4 compartments (mucosal, cutaneous, neural, and vascular). Two reference lines were identified (mucosal and external-internal auditory canal lines) intersecting at the level of the middle ear. The localization of contents relative to these reference lines was then described, and 2 methods of segmentation (the X method and the V method) were then proposed. This description was then used to describe middle ear relationships, facial nerve anatomy, and air cell distribution. CONCLUSIONS This new compartmental approach allows a comprehensive understanding of the distribution of petrous pyramid contents. Dividing it into anatomic compartments, and then navigating this mental map along specific reference points, lines, spaces, and segments, could create a useful tool to teach or learn its complex tridimensional anatomy.
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Affiliation(s)
- Mamdouh Tawfik-Helika
- Department of Neurosurgery, Beaujon University Hospital, Assistance publique hopitaux de Paris, Clichy, France.
| | | | - Guilherme Ribas
- Department of Surgery, University of São Paulo Medical School, São Paulo, Brazil
| | - Michael D Cusimano
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Martin Catala
- Sorbonne Université, CNRS UMR 7622, INSERM ERL 1156, IBPS, Paris, France
| | - Ramez Kirollos
- Senior Consultant, National Neuroscience Institute, Singapore
| | - Timothée Jacquesson
- Department of Anatomy, University of Lyon 1, Lyon, France; Skull Base Multi-disciplinary Unit, Department of Neurosurgery B, Neurological Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon Cedex, France
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17
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Bernard F, Troude L, Laccourreye L, Roche PH, Fournier HD. Stereoscopic Surgical Video of Combined Petrosectomy With Virtual Reality Headset: 3-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2018; 16:638-639. [DOI: 10.1093/ons/opy228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 07/23/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
The use of 3-dimensional (3D) videos allows students to visualize surgical procedures from the perspective of the surgeon without missing the essential parts.1 This 3D commented video demonstrates the operative technique and surgical nuances of the combined petrosectomy, visualize using virtual reality headsets.
Historically, traditional intradural cisternal routes using suboccipital and pterional approaches have been proposed to remove petroclival tumors.2-5 It allows rapid identification of neurovascular structures and a short exposure time. However, access to the petroclival region is far, not direct, and requires intradural cerebral retraction.6
In order to improve the access for tumoral dissection, lateral transpetrosal approaches have been proposed.7-12 The extradural route shortened the distance to the petroclival region, allows to better preserve the veins, to decrease the cerebral retraction, to interrupt early the tumor vascular supply, and a larger extent of resection.6 Transpetrosal approaches includes middle fossa approach8,10 (removing the petrous apex), posterior petrosal approach9,13,14 (removing of presigmoid retrolabyrinthine bone), and translabyrinthine petrosectomy.12
A combined petrosectomy may be used to approach larger tumor extending across the clival midline, upward to the tentorium or downward to the lower cranial nerves.6,10,15,16 Alternatively, according to Nanda, a retro-sigmoid approach may need to be performed to avoid critical draining veins injury.10,17 Good resection and outcomes are obtained when experienced surgeons use familiar approaches and microsurgical techniques.10
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Affiliation(s)
| | - Lucas Troude
- Department of Neurosurgery, North University Hospital, APHM, Marseille, France
| | | | - Pierre-Hugues Roche
- Department of Neurosurgery, North University Hospital, APHM, Marseille, France
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18
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Mercier P, Bernard F. Surgical anatomy for hemifacial spasm. Neurochirurgie 2018; 64:124-132. [PMID: 29779610 DOI: 10.1016/j.neuchi.2018.04.008] [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: 01/29/2018] [Revised: 02/05/2018] [Accepted: 04/13/2018] [Indexed: 02/08/2023]
Abstract
Classically in the cerebello-pontine angle the facial (CN VII) and vestibular-cochlear (CN VIII) nerves should run parallel with the anterior inferior cerebellar artery, whereas the lower nerves (CN IX-XI) continue with the posterior-inferior-cerebellar artery (PICA). In fact, this is not always true, particularly when dealing with hemispasm surgery where the relationships between CN VII, CN VIII and PICA are often different and closer. Knowledge of anatomical bases in surgical situation will help neurosurgeons to appreciate anatomical nuances, that are important to increase effectiveness and safety of hemifacial spasm surgery.
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Affiliation(s)
- P Mercier
- Department of anatomy, UFR de médecine, university of Angers, rue haute-de-reculée, 49045 Angers cedex, France.
| | - F Bernard
- Department of anatomy, UFR de médecine, university of Angers, rue haute-de-reculée, 49045 Angers cedex, France; Department of neurosurgery, CHU d'Angers, rue Larrey, 49033 Angers cedex, France
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19
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Abstract
The complex anatomy of petrous part of temporal bone makes the craniotomy around this area challenging. To avoid damaging the interior structures of petrous part of temporal bone, the authors used computed tomography to get the projection of the petrous part of temporal bone on skulls, making the external contours of petrous part clear, thus protecting its interior structure as a reference in craniotomy. The objective of this study was to find out the three-dimensional location of 4 points of petrous part of temporal bone. Parameters of 120 patients (240 observations) between 25 and 65 years who were free of abnormalities and pathological changes in temporal bone were measured on high-resolution spiral multiple slice computed tomographic multiple planar reconstruction images that were parallel to the base plane. The data were analyzed by SPSS, statistical software with the comparison between sides and sexes. The authors found the accurate locations that 4 points of petrous part of temporal bone with mastoidale as the origin. Then the authors connect the 3 vertexes of underside and the petrous apex and lengthen it until intersect with skulls to get the external landmarks. In the end, the authors get the safe range that can be applied to the clinical surgery.
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20
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Jiang Y, Chen Y, Yao J, Tian Y, Su L, Li Y. Anatomic Assessment of Petrous Internal Carotid Artery, Facial Nerve, and Cochlea Through the Anterior Transpetrosal Approach. J Craniofac Surg 2016; 26:2180-3. [PMID: 26468807 DOI: 10.1097/scs.0000000000000207] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to measure the related parameters of the cochlea, so as to allow preoperative assessment of the anatomic relationship of the petrous internal carotid artery (ICA), the facial nerve (FN), and the cochlea during skull base surgery. Seven parameters of these 3 structures were examined in the computed tomographic scan of 120 patients. The shortest distance from the cupula cochleae to the petrous ICA and the FN is as follows: 19.39 (1.01) mm to the stylomastoid foramen (D2), 10.27 (0.80) mm to the midpoint of the genu of FN canal (D3), 13.66 (0.88) mm to the exocranial opening of the carotid canal (D4), and 5.64 (1.03) mm to the midpoint of carotid knee (D5). The shortest distance between the mastoid segment of FN canal and the vertical segment of the petrous ICA (D6) was 13.33 (1.25) mm. The angle between D2 and D3 was measured at 45.66 (3.31)°, and the angle between D4 and D5 was measured at 41.08 (2.64)°. Clinically, it is relatively safe to work within the distances and angles measured in this research, and these results may give surgeons a practical and specific view of these 3 structures in the skull base approaches such as anterior transpetrosal approach to achieve the best possible surgical outcome and maximize safety.
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Affiliation(s)
- Ying Jiang
- *Department of Dermatology, the First Affiliated Hospital of Jilin University †Department of the Human anatomy, Jilin Medical College ‡Department of the Human anatomy, Norman Bethune College of Medicine, Jilin University, Changchun, China
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21
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Detailed anatomy knowledge: first step to approach petroclival meningiomas through the petrous apex. Anatomy lab experience and surgical series. Neurosurg Rev 2016; 40:231-239. [PMID: 27194133 DOI: 10.1007/s10143-016-0754-3] [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: 12/10/2015] [Revised: 05/09/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
Abstract
Petroclival meningiomas are a challenge for neurosurgeons due to the complex anatomy of the region that is rich of vessels and nerves. A perfect and detailed knowledge of the anatomy is very demanding in neurosurgery, especially in skull base surgery. The authors describe the microsurgical anatomy to perform an anterior petrosectomy based on their anatomical and surgical experience and perform a literature review. The temporal bone is the most complex and fascinating bone of skull base. The apex is located in the angle between the greater wing of the sphenoid and the occipital bone. Removing the petrous apex exposes the clivus. The approach directed through the temporal bone in this anatomical area is referred to as an anterior petrosectomy. The area that must be drilled is the rhomboid fossa that is defined by the Kawase, premeatal, and postmeatal triangles. In Division of Neurosurgery - University of Turin, 130 patients, from August 2013 to September 2015, underwent surgical resection of intracranial meningiomas. In this group, we have operated 7 PCMs and 5 of these were approached performing an anterior petrosectomy with good results. In our conclusions, we feel that this surgery require an advanced knowledge of human anatomy and a specialized training in interpretation of radiological and microsurgical anatomy both in the dissection lab and in the operating room.
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22
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Turan N, Baum GR, Holland CM, Ahmad FU, Henriquez OA, Pradilla G. Upper Nasopharyngeal Corridor for Transnasal Endoscopic Drainage of Petroclival Cholesterol Granulomas: Alternative Access in Conchal Sphenoid Patients. J Neurol Surg Rep 2015; 77:e017-22. [PMID: 26929897 PMCID: PMC4726374 DOI: 10.1055/s-0035-1567865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 09/14/2015] [Indexed: 11/25/2022] Open
Abstract
Background Cholesterol granulomas arising at the petrous apex can be treated via traditional open surgical, endoscopic, and endoscopic-assisted approaches. Endoscopic approaches require access to the sphenoid sinus, which is technically challenging in patients with conchal sphenoidal anatomy. Clinical Presentation A 55-year-old woman presented with intermittent headaches and tinnitus. Formal audiometry demonstrated moderately severe bilateral hearing loss. CT of the temporal bones and sella revealed a well-demarcated expansile lytic mass. MRI of the face, orbit, and neck showed a right petrous apex mass measuring 22 × 18 × 19 mm that was hyperintense on T1- and T2-weighted images without enhancement, consistent with a cholesterol granuloma. The patient had a conchal sphenoidal anatomy. Operative Technique Herein, we present an illustrative case of a low-lying petroclival cholesterol granuloma in a patient with conchal sphenoidal anatomy to describe an alternative high nasopharyngeal corridor for endoscopic transnasal transclival access. Postoperative Course Postoperatively, the patient's symptoms recovered and no complications occurred. Follow-up imaging demonstrated a patent drainage tract without evidence of recurrence. Conclusion In patients with a conchal sphenoid sinus, endoscopic transnasal transclival access can be gained using a high nasopharyngeal approach. This corridor facilitates safe access to these lesions and others in this location.
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Affiliation(s)
- Nefize Turan
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
| | - Griffin R Baum
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
| | - Christopher M Holland
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
| | - Faiz U Ahmad
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
| | - Oswaldo A Henriquez
- Emory University School of Medicine, Department of Otolaryngology, Head and Neck Surgery, Atlanta, GA, United States
| | - Gustavo Pradilla
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, GA, United States
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23
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Anatomic comparison of anterior petrosectomy versus the expanded endoscopic endonasal approach: interest in petroclival tumors surgery. Surg Radiol Anat 2015; 37:1199-207. [PMID: 26067921 DOI: 10.1007/s00276-015-1497-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/23/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Since the petroclival region is deep-seated with close neurovascular relationships, the removal of petroclival tumors still represents a fascinating surgical challenge. Although the classical anterior petrosectomy (AP) offers a meaningful access to this petroclival region, the expanded endoscopic endonasal approach (EEEA) recently leads to overcome difficulties from trans-cranial approaches. Herein, we present an anatomic comparison of AP versus EEEA. We aim to describe the limits of these both approaches helping the choice of the optimal surgical route for petroclival tumors. METHODS Six fresh cadaveric heads were harvested and injected with colored latex. Each approach was step-by-step detailed until its final surgical exposure. RESULTS The AP provided a narrow direct supero-lateral access to the petroclival area that can also reach the cavernous sinus, the retrochiasmatic region and perimesencephalic cisterns. However, this corridor anterior to the internal acoustic meatus passed on each side of the trigeminal nerve. Moreover, tumor extensions toward the foramen jugularis, inside the clivus or behind the internal acoustic meatus were difficult to control. The EEEA brought a straightforward access to the clivus but the petrous apex was hidden behind the internal carotid artery. Several variants were described: a medial transclival, a lateral through the Meckel's cave and an inferior trans-pterygoid route. Elsewhere, tumor extension behind the internal acoustic meatus or above the tentorium could not be satisfactorily assessed. DISCUSSION AND CONCLUSION PA and EEEA have their own limits in reaching the petroclival region in accordance with the tumor characteristics. The AP should be preferred for radical removal of middle-sized petrous apex intradural tumors like meningiomas. The EEEA would be of interest for extradural midline tumors like chordomas or for petrous apex cysts drainage.
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Jacquesson T, Berhouma M, Tringali S, Simon E, Jouanneau E. Which Routes for Petroclival Tumors? A Comparison Between the Anterior Expanded Endoscopic Endonasal Approach and Lateral or Posterior Routes. World Neurosurg 2015; 83:929-36. [PMID: 25700970 DOI: 10.1016/j.wneu.2015.02.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 01/30/2015] [Accepted: 02/02/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Petroclival tumors remain a surgical challenge. Classically, the retrosigmoid approach (RSA) has long been used to reach such tumors, whereas the anterior petrosectomy (AP) has been proposed to avoid crossing cranial nerves. More recently, the endoscopic endonasal approach has been "expanded" (i.e., EEEA) to the petroclival region. We aimed to compare these 3 approaches to help in the surgical management of petroclival tumors. METHODS Petroclival approaches were performed on 5 specimens after they were prepared with formaldehyde colored via latex injection. RESULTS The EEEA provides a simple straightforward route to the clivus, but reaching the petrous apex requires the surgeon to circumvent the internal carotid artery either via a medial transclival, an inferior transpterygoid, or a lateral variant through the Meckel's cave. In contrast, the AP offers a narrow direct superolateral access to the petroclival region crossed by the trigeminal nerve. Finally, the RSA provides a wide simple and quick exposure of the cerebellopontine angle, but access to the petroclival region needs the surgeon to deal with the V(th) to XI(th) cranial nerves. DISCUSSION/CONCLUSION The EEEA should be preferred for extradural midline tumors (chordomas, chondrosarcomas) or for cystic lesions when drainage is essential. The AP could be optimal for the radical removal of intradural vascularized tumors (meningiomas) with intrapetrous or supratentorial extensions. The RSA retains an advantage for small or cystic tumors near the internal acoustic meatus. The skull base surgeon has to master all of these routes to choose the more appropriate one according to the surgical objective, the tumor characteristics, and the patient's medical status.
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Affiliation(s)
- Timothée Jacquesson
- Skull Base Multidisciplinary Unit, Department of Neurosurgery, Neurological Hospital Pierre Wertheimer, Lyon Cedex, France; Department of Anatomy, University of Lyon, Lyon, France.
| | - Moncef Berhouma
- Skull Base Multidisciplinary Unit, Department of Neurosurgery, Neurological Hospital Pierre Wertheimer, Lyon Cedex, France
| | - Stéphane Tringali
- Skull Base Multidisciplinary Unit, Department of Neurosurgery, Neurological Hospital Pierre Wertheimer, Lyon Cedex, France; Department of Otorhinolaryngology, Pierre Benite, France
| | - Emile Simon
- Department of Anatomy, University of Lyon, Lyon, France
| | - Emmanuel Jouanneau
- Skull Base Multidisciplinary Unit, Department of Neurosurgery, Neurological Hospital Pierre Wertheimer, Lyon Cedex, France
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Gagliardi F, Boari N, Roberti F, Caputy AJ, Mortini P. Operability score: An innovative tool for quantitative assessment of operability in comparative studies on surgical anatomy. J Craniomaxillofac Surg 2014; 42:1000-4. [DOI: 10.1016/j.jcms.2014.01.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 09/30/2013] [Accepted: 01/06/2014] [Indexed: 11/24/2022] Open
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Selection of surgical approaches based on semi-quantifying the skull-base invasion by petroclival meningiomas: a review of 66 cases. Acta Neurochir (Wien) 2014; 156:1085-97. [PMID: 24752725 DOI: 10.1007/s00701-014-2084-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 03/25/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Petroclival meningiomas are still challenging for neurosurgeons. In the present study, we reviewed 66 petroclival meningiomas that underwent craniotomy to assess the surgical approaches for petroclival meningiomas based on semi-quantifying tumor extension to skull base and to evaluate the outcomes. METHODS According to invasion characteristics, skull base related to petroclival meningiomas was semi-quantitatively divided into five regions: upper, middle, and lower petroclival regions (region A, B, and C, respectively), cerebellopontine angle region (region D), and parasellar and cavernous sinus region (region E). Appropriate surgical approaches were adopted for petroclival meningiomas with varying degrees of invasion, including the subtemporal (11/66), retrosigmoid (15/66), presigmoid (32/66), combined retrosigmoid and far-lateral (2/66), supra-infratentorial (4/66), and extended middle cranial fossa (2/66) approaches. RESULTS The results showed that involvement of region A, B, and C was in 64, 50, and eight patients, respectively. Invasion to region D and E occurred in 13 and 39 cases, respectively. The ratio of single region involvement was only 7.6 %, whereas most petroclival meningiomas tended to invade more regions (39.4 % for two, 37.9 % for three, 12.1 % for four, and 3.0 % for five regions, respectively). Gross total resection was achieved in 29 cases (43.9 %), near total resection in 27 cases (40.9 %), and subtotal resection in ten cases (15.2 %). After a mean follow-up period of 32.21 months, obvious cranial nerve deficits existed in seven patients, and recurrence occurred in eight patients. CONCLUSIONS We introduced a simple and practicable method for classification of petroclival meningiomas, which could semi-quantify tumor invasion and help to select surgical approaches. With careful preoperative evaluation, a cautiously selected approach would improve the prognosis.
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Adams Pérez J, Rassier Isolan G, Pires de Aguiar PH, Antunes AM. Volumetry and analysis of anatomical variants of the anterior portion of the petrous apex outlined by the kawase triangle using computed tomography. J Neurol Surg B Skull Base 2014; 75:147-51. [PMID: 25072007 DOI: 10.1055/s-0033-1356491] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 07/15/2013] [Indexed: 10/25/2022] Open
Abstract
Background Anterior petrosectomy has become an increasingly used approach for petroclival lesions. This study measures the volume and the anatomical variants of the anterior portion of the petrous apex outlined by the Kawase triangle using computed tomography (CT). Methods This was a transversal retrospective study. We assessed the anterior petrous apex portion outlined by the Kawase triangle in consecutive patients > 18 years of age from CT scans of temporal bone stored in an archive system. The volumetry was performed on a workstation. Results A total of 154 petrosal apex were analyzed in 77 patients (36 men). The average volume of the region outlined by the Kawase triangle was 1.89 ± 0.52 cm(3). The volume average in men was 2.01 ± 0.58 cm(3), and the average in women was 1.79 ± 0.41 cm(3). Intra- and interobserver agreement were both excellent, and there was little variance. Nineteen petrous apex demonstrated anatomical variations. In 18 cases it was pneumatized, and in one case a vascular or nerve-like structure was identified, a report we did not find in the literature. Conclusion The volumetry of the petrous apex anterior portion outlined by the Kawase triangle can be made by CT with excellent intra- and interobserver agreement and reproducibility. There are anatomical variants in this region that are relevant to surgery.
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Affiliation(s)
- Juliano Adams Pérez
- Department of Neurosurgery, Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Gustavo Rassier Isolan
- Department of Neurosurgery, Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Paulo Henrique Pires de Aguiar
- Department of Neurosurgery, Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Apio Martins Antunes
- Department of Neurosurgery, Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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Zhou JY, Lu JH, Zhen XY, Wang W, Xu JF, Hu WW. Microsurgical anatomical study of the frontotemporal-zygomatic arch approach to the superior petroclival region. Exp Ther Med 2012; 2:1211-1214. [PMID: 22977646 DOI: 10.3892/etm.2011.345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 08/22/2011] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to explore the microsurgical anatomy of the superior petroclival region, and thus provide an anatomical basis for operative approaches. The frontotemporal-orbitozygomatic approach was performed on 20 sides of 10 adult cadaver heads. In comparison to the range of the exposure with the removal of the anterior clinoid process, posterior clinoid process and part of the tip of the petrous bone, we measured the neurovascular course and their relation to the superior petroclival region. We found that the trochlear nerve goes through the edge of the tentorial marginal branch, taking 5.42 mm (4.26-6.96) away from the ophthalmic nerve. Exposing the arteria basilaris, above the middle piece the length of exposure is 15.52 mm (14.22-16.70), resulting in the posterior cerebral artery and the front part of the midbrain being completely exposed. There is little exposure on the front part of the pons and midbrain with a length of 5.6 mm (4.38-6.82). Removing the partial petrosal bones, the inferior segment of the basal artery is exposed, while 4 other nerves cab also be observed: Cranial, abducens, facial and vestibulocochlear. The frontotemporal-zygomatic arch approach can clearly expose the superior petroclival region. Obtaining more information on the relationship between the location of these structures, is therefore helpful in improving the safety and success of surgery in this region.
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Affiliation(s)
- Jing-Yi Zhou
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, P.R. China
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Extradural Subtemporal Transzygomatic Approach to the Clival and Paraclival Region With Endoscopic Assist. J Craniofac Surg 2012; 23:1468-75. [DOI: 10.1097/scs.0b013e31825a6497] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Roche PH, Lubrano V, Noudel R, Melot A, Régis J. Decision making for the surgical approach of posterior petrous bone meningiomas. Neurosurg Focus 2011; 30:E14. [PMID: 21529170 DOI: 10.3171/2011.2.focus1119] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors undertook this study to examine the surgical approaches used to treat posterior petrous bone meningiomas at a single institution and retrospectively evaluate their surgical strategy based on a previously published classification. METHODS Cases in which craniotomies were performed to treat posterior petrous bone meningiomas between 2002 and 2010 were retrospectively reviewed. Data were examined from 57 patients who were treated for 59 tumors. The tumors were classified into 3 types according to the location of their primary dural attachment: Type A, located around the porus trigeminus (33 tumors); Type M, located at the level of the porus of the internal auditory canal (IAC) (12 tumors); and Type P, located laterally to the IAC (14 tumors). The median tumor diameter was 34 mm (range 20-67 mm). RESULTS The choice of the approach was based on tumor location, as the displacement of vascular structures and cranial nerves was primarily determined by the site of dural attachment on the posterior petrous bone. An anterior petrosectomy was performed in 82% of Type A meningiomas, and a retrosigmoid approach was used in 86% of Type P meningiomas. The spectrum of approaches was less uniform for Type M meningiomas. Overall, total resection was obtained in 39% of all cases, and in 18%, 50%, and 86% of Type A, Type M, and Type P tumors, respectively. The postoperative mortality rate was 8.8% (5 deaths among 57 patients), and all 5 patients who died during the early postoperative period had large Type A tumors. At last follow-up, the functional preservation of the facial nerve was excellent in 49 (94%) of the 52 surviving patients. CONCLUSIONS The authors believe that proper selection of the approach favorably impacts functional outcome in patients undergoing surgery for the treatment of skull base tumors. In the authors' case series of posterior petrous bone meningiomas, Type P and most Type M tumors were safely managed through a regular retrosigmoid approach, whereas Type A tumors were optimally treated via an epidural anterior petrosectomy.
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Affiliation(s)
- Pierre-Hugues Roche
- CHU Marseille Nord APHM, Université de la Méditerrannée, Chemin des Bourelly, Marseille Cedex 20, France.
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Liu XD, Xu QW, Che XM, Mao RL. Anatomy of the petrosphenoidal and petrolingual ligaments at the petrous apex. Clin Anat 2009; 22:302-6. [DOI: 10.1002/ca.20771] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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[Management of bone-invasive en-plaque petrosal meningiomas. Removal using tailored petrosectomy]. Neurochirurgie 2008; 55:25-35. [PMID: 18848338 DOI: 10.1016/j.neuchi.2008.08.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2008] [Accepted: 08/20/2008] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE The invasion of bone responsible for hyperostosis is a typical phenomenon associated with en-plaque meningiomas. Although the sphenoid wing and spheno-orbital region are most frequently affected, petrosal involvement is rare and its surgical treatment difficult. Hyperostosis is caused by bone invasion, is responsible for the clinical signs, and prompts the surgeon to use an à la carte drilling that has to be evaluated preoperatively and carried out depending on tumor extension and the treatment goals. METHODS We report two cases of invasive and evolving en-plaque petrosal meningiomas. Hyperostosis, bony modifications, and intracranial portion of the lesion were responsible for cophosis, facial palsy, trigeminal neuralgia, dysphonia, and laryngeal palsy in one case, and were responsible for hearing loss and facial palsy in the other case. RESULTS In both cases, the à la carte petrosectomy allowed us to achieve total removal of the lesion. In one case, we used a trans- and infralabyrinthine transjugular approach (to control the extension of the lesion in the jugular foramen, within the sinusojugular axis, and in the internal auditory canal), associated with an anterior petrosectomy (to control the invaded petrous apex, Meckel's cave, and a middle cranial fossa extension). In the other case, we used a retro- and infralabyrinthine transsigmoid transtentorial approach to control the venous axis, the posterior fossa dura, and the tentorium. Total removal of the tumor including bone invasion was achieved in both cases. Neurological deficits improved or remain unchanged. Transient postoperative facial palsy recovered in two months. CONCLUSIONS An à la carte petrosectomy performed by a surgical team with great expertise in the field of petrous bone anatomy and segmentation should lead to total removal including exposure of the dural tail and intracranial portion of the tumor, while preserving all cranial nerve functions.
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