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Jian ZH, Sheng MF, Liao CC, Weng ZJ, Li JY, Yi XF, Chen G. A novel theory for rapid localization of the transverse-sigmoid sinus junction and "keyhole" in the retrosigmoid keyhole approach: micro-anatomical study, technique nuances, and clinical application. Neurosurg Rev 2024; 47:331. [PMID: 39008189 PMCID: PMC11249418 DOI: 10.1007/s10143-024-02583-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 05/20/2024] [Accepted: 07/08/2024] [Indexed: 07/16/2024]
Abstract
To determine a rapid and accurate method for locating the keypoint and "keyhole" in the suboccipital retrosigmoid keyhole approach. (1) Twelve adult skull specimens were selected to locate the anatomical landmarks on the external surface of the skull.The line between the infraorbital margin and superior margin of the external acoustic meatus was named the baseline. A coordinate system was established using the baseline and its perpendicular line through the top point of diagastric groove.The perpendicular distance (x), and the horizontal distance (y) between the central point of the "keyhole" and the top point of the digastric groove in that coordinate system were measured. The method was applied to fresh cadaveric specimens and 53 clinical cases to evaluate its application value. (1) x and y were 14.20 ± 2.63 mm and 6.54 ± 1.83 mm, respectively (left) and 14.95 ± 2.53 mm and 6.65 ± 1.61 mm, respectively (right). There was no significant difference between the left and right sides of the skull (P > 0.05). (2) The operative area was satisfactorily exposed in the fresh cadaveric specimens, and no venous sinus injury was observed. (3) In clinical practice, drilling did not cause injury to venous sinuses, the mean diameter of the bone windows was 2.0-2.5 cm, the mean craniotomy time was 26.01 ± 3.46 min, and the transverse and sigmoid sinuses of 47 patients were well-exposed. We propose a "one point, two lines, and two distances" for "keyhole" localization theory, that is we use the baseline between the infraorbital margin and superior margin of the external acoustic meatus and the perpendicular line to the baseline through the top point of the digastric groove to establish a coordinate system. And the drilling point was 14.0 mm above and 6.5 mm behind the top point of the digastric groove in the coordinate system.
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Affiliation(s)
- Zhi-Heng Jian
- Neurosurgery Department, Zhuhai People's hospital (Zhuhai Clinical Medical College of Jinan University, Zhuhai, Guangdong Province, China
| | - Min-Feng Sheng
- Second affiliated hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Chang-Chun Liao
- Neurosurgery Department, Zhuhai People's hospital (Zhuhai Clinical Medical College of Jinan University, Zhuhai, Guangdong Province, China
| | - Zhi-Jian Weng
- Neurosurgery Department, Zhuhai People's hospital (Zhuhai Clinical Medical College of Jinan University, Zhuhai, Guangdong Province, China
| | - Jia-Yan Li
- Neurosurgery Department, Zhuhai People's hospital (Zhuhai Clinical Medical College of Jinan University, Zhuhai, Guangdong Province, China
| | - Xin-Feng Yi
- Neurosurgery Department, Zhuhai People's hospital (Zhuhai Clinical Medical College of Jinan University, Zhuhai, Guangdong Province, China
| | - Gang Chen
- Neurosurgery Department, Zhuhai People's hospital (Zhuhai Clinical Medical College of Jinan University, Zhuhai, Guangdong Province, China.
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Gilkes A, Rajaram-Gilkes M, Cardona JJ, Reina F, Carrera A, Iwanaga J, Dumont AS, Donofrio CA, Badaloni F, Fioravanti A, Tubbs RS. The Occipitalis Muscle as an Adjunct Superficial Landmark for the Transverse Sinus and Transverse-Sigmoid Junction: An Anatomical Study With Application to Posterior Cranial Fossa Surgery. Cureus 2023; 15:e39723. [PMID: 37398761 PMCID: PMC10310057 DOI: 10.7759/cureus.39723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
INTRODUCTION Although neuronavigation systems are widely used for identifying deep intracranial structures, additional superficial anatomical landmarks can be useful when this technology is not available or is not working properly. Herein, we investigate the potential of the occipitalis muscle (OM), rarely mentioned in neurosurgical literature, as a superficial landmark for the transverse sinus (TS) and transverse-sigmoid sinus junction (TSJ). METHODS Eighteen adult cadaveric heads underwent dissection. The borders of the OM were identified and measured. The muscle was then removed and the bone underlying the muscle was drilled. The relationships between the OM and the underlying dural venous sinuses were then investigated by using a surgical microscope. RESULTS The OM is a quadrangular-shaped muscle, that invariably crosses the lambdoid suture, showing relationships with the TS inferiorly and the TSJ laterally. The medial border was located a mean of 2.7 cm from the midline and its lower edge was a mean of 1.6 cm above the TS. The inferior border was found between the lambdoid suture and the superior nuchal line in all the specimens. The medial half of the inferior margin was placed on average 1.1 cm superiorly to the TS while the lateral margin ran just above or over the TS. The lateral border was located a mean of 1.1 cm medially to the asterion and approximated the mastoid notch, being within 1-2 cm from it. The TSJ was between 2.1 and 3.4 cm lateral to OM lateral border. CONCLUSION A combination of superficial anatomical landmarks can be useful for surgical planning. We found that the OM represents a valuable aide for neurosurgeons and is a reliable landmark for the deeper-lying TS and TSJ.
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Affiliation(s)
- Aishwarya Gilkes
- Department of Anatomical Sciences, St. George's University, St. George's, GRD
| | | | - Juan J Cardona
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, USA
| | - Francisco Reina
- Department of Medical Sciences, Clinical Anatomy, Embryology and Neurosciences Research Group (NEOMA) Faculty of Medicine, University of Girona, Girona, ESP
| | - Ana Carrera
- Department of Medical Sciences, Clinical Anatomy, Embryology and Neurosciences Research Group (NEOMA) Faculty of Medicine, University of Girona, Girona, ESP
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, USA
- Department of Neurology, Tulane University School of Medicine, New Orleans, USA
- Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, USA
- Department of Oral and Maxillofacial Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, JPN
- Dental and Oral Medical Center, Kurume University School of Medicine, Kurume, JPN
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, USA
| | - Carmine Antonio Donofrio
- Department of Molecular and Translational Medicine, Division of Biology and Genetics, Faculty of Medicine, University of Brescia, Brescia, ITA
- Department of Neurosurgery, ASST Cremona, Cremona, ITA
| | - Filippo Badaloni
- Department of Neurosurgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto delle Scienze Neurologiche di Bologna, Bologna, ITA
| | | | - R Shane Tubbs
- Department of Anatomical Sciences, St. George's University, St. George's, GRD
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, USA
- Department of Neurology, Tulane University School of Medicine, New Orleans, USA
- Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, USA
- Department of Surgery, Tulane University School of Medicine, New Orleans, USA
- Department of Neurosurgery, Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, USA
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Jian ZH, Sheng MF, Li JY, Li Y, Weng ZJ, Chen G. Precise Localization in Craniotomy With a Retrosigmoid Keyhole Approach: Microsurgical Anatomy and Clinical Study. Front Surg 2022; 9:809098. [PMID: 35495767 PMCID: PMC9046933 DOI: 10.3389/fsurg.2022.809098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/25/2022] [Indexed: 11/24/2022] Open
Abstract
Objective We aimed to explore a method of precise localization within craniotomy based on skull anatomical landmarks via the suboccipital retrosigmoid approach. Method Craniometric measurements were taken from 15 adult dry skulls and eight cadaver head specimens. In the anatomical study, the keypoint corresponded to the transverse-sigmoid sinus junction's corresponding point on the external surface of the temporal mastoid process, eight cadaveric heads underwent a simulated craniotomy using the suboccipital retrosigmoid approach. The center of the burr hole is precisely oriented 12 mm vertically above the top point of the mastoid groove based on the line between the infraorbital margin and the upper edge of the external auditory canal. Clinical application was verified in clinical surgery by evaluating the accuracy, safety, rapidity, and minimal invasiveness of the procedure in 29 patients. Result No venous sinus injuries were observed. Within clinical application, 29 patients underwent craniotomy using the suboccipital retrosigmoid approach. The operative area was clearly exposed in all patients and the microsurgical anatomy of the intracranial region after the dura mater incision was satisfactory. No venous sinus ruptures were observed. The average craniectomy time was 27.02 ± 0.86 min. The diameter of the bone window was 1.7–2.9 cm. Conclusion We conclude that the method can ensure safe, accurate, and rapid craniotomy with good vision while avoiding injury to the venous sinus.
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Affiliation(s)
- Zhi-Heng Jian
- Department of Neurosurgery, Zhuhai People's Hospital, Jinan University, Zhuhai, China
| | - Min-Feng Sheng
- Department of Neurosurgery, Second Affiliated Hospital, Soochow University, Suzhou, China
| | - Jia-Yan Li
- Department of Neurosurgery, Zhuhai People's Hospital, Jinan University, Zhuhai, China
| | - Yu Li
- Department of Neurosurgery, Zhuhai People's Hospital, Jinan University, Zhuhai, China
| | - Zhi-Jian Weng
- Department of Neurosurgery, Zhuhai People's Hospital, Jinan University, Zhuhai, China
| | - Gang Chen
- Department of Neurosurgery, Zhuhai People's Hospital, Jinan University, Zhuhai, China
- *Correspondence: Gang Chen
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Jian ZH, Sheng MF, Li JY, An DZ, Weng ZJ, Chen G. Developing a Method to Precisely Locate the Keypoint During Craniotomy Using the Retrosigmoid Keyhole Approach: Surgical Anatomy and Technical Nuances. Front Surg 2021; 8:700777. [PMID: 34692760 PMCID: PMC8531805 DOI: 10.3389/fsurg.2021.700777] [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: 04/26/2021] [Accepted: 09/10/2021] [Indexed: 11/23/2022] Open
Abstract
Objective: To explore the precise location of the keypoint during craniotomy using the retrosigmoid keyhole approach. Methods: This study included 20 dry skulls and 10 wet cadaveric specimens. On the inner surface of dry skulls, the junction between the inferior margin of the transverse sinus (ITS) and the posterior margin of the sigmoid sinus (TSJ) was marked. The keypoint (D) was identified as the TSJ's corresponding point on the external surface of the temporal mastoid process (MP). The distance from the keypoint to the top point of the digastric groove, mastoidale, and asterion were noted (AD, BD, CD, respectively). A method to accurately locate the keypoint was developed based on these relationships. The developed method was used on the wet cadaveric specimens to evaluate its accuracy, safety, rapidity, and minimal invasion. Results: No significant difference was found between the AD, BD, and CD of the left and right sides. The drilling point was oriented on a straight line 12 mm above the top point of digastric groove, perpendicular to the Frankfort horizontal plane (FHP). In the cadaveric specimens, the operative area was clearly exposed. No venous sinus rupture occurred. The average craniotomy time was 28.74 ± 3.89 min. Conclusions: A potentially safe, accurate, and rapid craniotomy procedure was developed with the added advantage of preserving the visibility of the operating field and preventing venous sinus injury.
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Affiliation(s)
- Zhi-Heng Jian
- Department of Neurosurgery, Zhuhai People's Hospital (Zhuhai Hospital Affiliated With Jinan University, China), Zhuhai, China
| | - Min-Feng Sheng
- Department of Neurosurgery, Second Affiliated Hospital of Soochow University, Soochow, China
| | - Jia-Yan Li
- Department of Neurosurgery, Zhuhai People's Hospital (Zhuhai Hospital Affiliated With Jinan University, China), Zhuhai, China
| | - De-Zhu An
- Department of Neurosurgery, Zhuhai People's Hospital (Zhuhai Hospital Affiliated With Jinan University, China), Zhuhai, China
| | - Zhi-Jian Weng
- Department of Neurosurgery, Zhuhai People's Hospital (Zhuhai Hospital Affiliated With Jinan University, China), Zhuhai, China
| | - Gang Chen
- Department of Neurosurgery, Zhuhai People's Hospital (Zhuhai Hospital Affiliated With Jinan University, China), Zhuhai, China
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Li R, Qi L, Yu X, Li K, Bao G. Mastoid notch as a landmark for localization of the transverse-sigmoid sinus junction. BMC Neurol 2020; 20:111. [PMID: 32220232 PMCID: PMC7099776 DOI: 10.1186/s12883-020-01688-2] [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: 11/21/2019] [Accepted: 03/16/2020] [Indexed: 11/28/2022] Open
Abstract
Background The top of the mastoid notch (TMN) is close to the transverse-sigmoid sinus junction. The spatial position relationship between the TMN and the key points (the anterosuperior and inferomedial points of the transverse-sigmoid sinus junction, ASTS and IMTS) can be used as a novel method to precisely locate the sinus junction during lateral skull base craniotomy. Methods Forty-three dried adult skull samples (21 from males and 22 from females) were included in the study. A rectangular coordinate system on the lateral surface of the skull was defined to assist the analysis. According to sex and skull side, the data were divided into 4 groups: male&left, male&right, female&left and female&right. The distances from the ASTS and IMTS to the TMN were evaluated on the X-axis and Y-axis, symbolized as ASTS&TMN_x, ASTS&TMN_y, IMTS&TMN_x and IMTS&TMN_y. Results Among the four groups, there was no significant difference in ASTS&TMN_x (p = 0.05) and ASTS&TMN_y (p = 0.3059), but there were significant differences in IMTS&TMN_x (p < 0.001) and IMTS&TMN_y (p = 0.01), and multiple comparisons indicated that there were significant differences between male&left and female&left both in IMTS&TMN_x (p = 0.0006) and in IMTS&TMN_y (p = 0.0081). In general, the ASTS was located 1.92 mm anterior to the TMN on the X-axis and 27.01 mm superior to the TMN on the Y-axis. For the male skulls, the IMTS was located 3.60 mm posterior to the TMN on the X-axis and 14.40 mm superior to the TMN on the Y-axis; for the female skulls, the IMTS was located 7.84 mm posterior to the TMN on the X-axis and 19.70 mm superior to the TMN on the Y-axis. Conclusions The TMN is a useful landmark for accurately locating the ASTS and IMTS.
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Affiliation(s)
- Ruichun Li
- Department of Neurosurgery, First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Lei Qi
- Department of Neurosurgery, First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Xiao Yu
- Department of Neurosurgery, First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Kuo Li
- Department of Neurosurgery, First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China
| | - Gang Bao
- Department of Neurosurgery, First Affiliated Hospital of Xi'an Jiaotong University, 277 West Yanta Road, Xi'an, 710061, Shaanxi, China.
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The Anatomy of the Sigmoid-Transverse Junction According to the Tentorial Angle. J Craniofac Surg 2019; 30:2280-2284. [PMID: 31369515 DOI: 10.1097/scs.0000000000005793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Dural sinuses have critical importance during intracranial approaches. Detailed anatomical knowledge of the dural sinuses is crucial for surgeons to reduce unexpected venous bleeding. The aim of this study was to investigate anatomical relation of sigmoid sinus and tentorium cerebelli according to clinically palpable landmarks and cranial morphometry. The authors evaluated 222 individuals' (94 women, 128 men) 3-dimensional computed tomography angiograms, retrospectively. The authors also studied on 12 mid-sagittal cut dried hemiskulls and 8 formalin fixed cadaver heads hemisected midsagitally. All measurements were completed using Osirix-Lite version 9 software. Craniometrical values were measured to define cranium morphology. Furthermore, level of the sigmoid sinus according to asterion and tentorial angle were evaluated in detail. Our results demonstrated that there were significant differences between parameters and genders, except vertical angle of the tentorium cerebelli. Distance between asterion and sigmoid sinus was statistically different between right and left sides in favor of the left side. This also varied depending on the position of the sigmoid sinus, as well. Only transverse angle between the upper point of external acoustic meatus and asterion demonstrated a significant correlation with age. This study evaluated the detailed 3D anatomy of sigmoid sinus and tentorium cerebelli related with the cranium morphology. Determining to sigmoid sinus anatomy according to clinically palpable landmarks has advantages for setting surgical protocols and reducing to unexpected injuries while surgery to these structures.
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Hall S, Peter Gan YC. Anatomical localization of the transverse-sigmoid sinus junction: Comparison of existing techniques. Surg Neurol Int 2019; 10:186. [PMID: 31637087 PMCID: PMC6778333 DOI: 10.25259/sni_366_2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 09/04/2019] [Indexed: 11/04/2022] Open
Abstract
Background Anatomical localization remains integral to neurosurgery, particularly in the posterior fossa where neuronavigation is less reliable. There have been many attempts to define the location of the transverse- sigmoid sinus junction (TSSJ) using anatomical landmarks, to aid in the placement of the "strategic burr hole" during a retrosigmoid approach. There is a paucity of research allowing direct comparison of such techniques. Methods Using high-resolution contrast-enhanced cranial computed tomography images, we constructed three-dimensional virtual cranial models. Fifty models (100 sides) were created from a retrospective sample of images performed in a New Zealand population. Ten methods of anatomical localization were applied to each model allowing qualitative and quantitative comparisons. The "key point" was defined as the point on the outer surface of the skull that directly overlaid the junction of the posterior fossa dura, transverse sinus (TS), and sigmoid sinus (SS). The proximity of each method to this "key point" was compared quantitatively, in addition to other descriptive observations. TSSJ localization methods analyzed included: (1) asterion; (2) emissary foramen; (3) Lang and Samii; (4) Day; (5) Rhoton; (6) Avci; (7) Ribas; (8) Tubbs; (9) Li; and (10) Teranishi. Results Mean distance to the "key point" showed two tiers of accuracy, those <10 mm, and those >10 mm: Li (6.3 mm), Ribas (6.6 mm), Tubbs (6.8 mm), Teranishi (7.8 mm), Day (8.4 mm), emissary foramen (12.0 mm), Avci (13.0 mm), asterion (13.9 mm), Lang and Samii (15.6 mm), and Rhoton (17.4 mm). The asterion would most frequently overlie the TS (63%) and was often supratentorial (14%). Conclusion Each method has a unique profile of dura or sinus exposure. There are significant differences in the accuracy of localization of the TSSJ among anatomical localization methods.
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Affiliation(s)
- Samuel Hall
- Department of Neurosurgery, Waikato District Health Board, Hamilton, New Zealand.,Department of Neurosurgery, Westmead Hospital, Sydney, Australia
| | - Yee-Chiung Peter Gan
- Department of Neurosurgery, Waikato District Health Board, Hamilton, New Zealand
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Li RC, Liu JF, Li K, Qi L, Yan SY, Wang MD, Xie WF. Localization of Anterosuperior Point of Transverse-sigmoid Sinus Junction Using a Reference Coordinate System on Lateral Skull Surface. Chin Med J (Engl) 2016; 129:1845-9. [PMID: 27453235 PMCID: PMC4976574 DOI: 10.4103/0366-6999.186633] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: During craniotomies using the transpetrosal-presigmoid approach, exposure of the sigmoid sinus remains an essential but hazardous step. In such procedures, accurate localization of the anterosuperior point of the transverse-sigmoid sinus junction (ASTS) is very important for reducing surgical morbidity. This study aimed to create an accurate and practical method for identifying the ASTS. Methods: On the lateral surfaces of 40 adult skulls (19 male skulls and 21 female skulls), a rectangular coordinate system was defined to measure the x and y coordinates of two points: the ASTS and the squamosal-parietomastoid suture junction (SP). With the coordinate system, the distribution characteristics of the ASTS were statistically analyzed and the differences between the ASTS and SP were investigated. Results: For ASTS-x, significant differences were found in different sides (P = 0.020); the ASTS-x in male skulls was significantly higher on the right side (P = 0.017); there was no significant difference between the sides in female skulls. There were no significant differences in gender or interaction of gender and side for ASTS-x, and for ASTS-y, there were no significant differences in side, gender, or interaction of gender and side. For both sides combined, the mean ASTS-x was significantly higher than the mean SP-x (P = 0.003) and the mean ASTS-y was significantly higher than the mean SP-y (P = 0.011). Conclusions: This reference coordinate system may be an accurate and practical method for identifying the ASTS during presigmoid craniotomy. The SP might be difficult to find during presigmoid craniotomy and, therefore, it is not always a reliable landmark for defining the ASTS.
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Affiliation(s)
- Rui-Chun Li
- Department of Neurosurgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Ji-Feng Liu
- Xi'an Center for Disease Control and Prevention, Xi'an, Shaanxi 710054, China
| | - Kuo Li
- Department of Neurosurgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Lei Qi
- Department of Neurosurgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Si-Yao Yan
- Department of Neurosurgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Mao-De Wang
- Department of Neurosurgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
| | - Wan-Fu Xie
- Department of Neurosurgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, China
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