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Marchioni D, Alberti C, Bisi N, Rubini A. Radiological Classification and Management Algorithm of Petrous Apex Cholesterol Granuloma. J Clin Med 2024; 13:2505. [PMID: 38731034 PMCID: PMC11084343 DOI: 10.3390/jcm13092505] [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: 03/29/2024] [Revised: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Petrous apex cholesterol granulomas (PACGs) are benign inflammatory cystic lesions of the temporal bone. Usually, asymptomatic patients may develop symptoms as the lesions expand. The diagnosis is based on both CT and MRI scans and the management relies on "wait and scan" or surgery. This paper aims at evaluating surgical outcomes and proposing a CT-based classification and a management algorithm. Methods: Patients with PACGs who were surgically treated between 2014 and 2024 were included. Symptoms, imaging, approach type and complications were considered. CT scans were classified as Type A (preserved apex cellularity), Type B (erosion of the apex cellularity), and Type C (involvement of the noble structures bone boundaries). The possible connection of the lesion with the infracochlear, perilabyrinthine and sphenoidal cellularity was assessed. Results: Nineteen patients with symptoms like diplopia, headache and sensorineural hearing loss were included. According to our classification, 1/19 patients was Type A, 4/19 were Type B and 14/19 were Type C. Five patients underwent a total resection, seven a subtotal and seven a surgical drainage. Only two complications were recorded, and 17/19 patients showed symptom regression and stability during follow-up. Conclusions: While the management of PACGs is still controversial, according to our classification and surgical outcomes, Type A, being mostly asymptomatic, should be managed with "wait and scan", Type B should undergo surgery when symptoms are present, while Type C should always undergo surgery because of their invasiveness and potential complications. When possible, a drainage should be attempted; otherwise, a surgical resection is chosen, and its completeness depends on the preoperative general and hearing status.
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Affiliation(s)
| | | | - Nicola Bisi
- Department of Otorhinolaryngology-Head and Neck Surgery, Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, 41125 Modena, Italy; (D.M.); (C.A.); (A.R.)
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Characteristics and Clinical Management Strategy of Petrous Apex Cholesterol Granulomas. Cancers (Basel) 2023; 15:cancers15041313. [PMID: 36831654 PMCID: PMC9953853 DOI: 10.3390/cancers15041313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/12/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
Purpose: To evaluate the clinical characteristics of petrous apex cholesterol granulomas (PACG) and assess outcomes after different treatment strategies. Method: A consecutive case series of 34 patients with a PACG. Main outcomes were PACG growth, symptoms, and the outcomes of different treatment strategies: wait-and-scan (WS) and surgical drainage. Results: Thirty-four patients were analyzed; mean follow-up time was 7.1 years. Twenty-one patients (61.7%) showed symptoms, mostly more than one. Most symptoms reported were cranial nerve palsy (58.8%) and headache (35.3%). Twenty-one patients (61.8%) received solely wait-and-scan (WS), and thirteen patients (38.2%) underwent surgery, five of whom (38.5%) after an initial WS period. In the solely WS group, one (4.8%) developed new symptoms, and two (9.5%) reported symptom progression despite a stable granuloma size. Two (9.5%) showed granuloma growth on follow-up scans without symptom progression. Surgery consisted of drainage. Eleven (84.6%) of these thirteen patients reported partial recovery; one (7.7%) reported no recovery; and one (7.7%) reported full recovery of reported symptoms related to PACG. Among the patients with cranial nerve involvement, 7.7% showed full recovery after surgery; 84.6% showed partial recovery; and 7.7% did not recover. Adverse events occurred in five out of 13 patients who underwent surgery, all with full recovery. Conclusions: This study confirms that PACG are slow-growing lesions with a low risk of adverse events. Solely using wait-and-scan strategy is a safe option for patients without symptoms, with acceptable symptoms without symptom progression, and with asymptomatic growth. Surgical treatment can be considered in patients with symptom progression or symptomatic growth.
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Bray HN, Sappington JM. A Review of Posterior Fossa Lesions. MISSOURI MEDICINE 2022; 119:553-558. [PMID: 36588644 PMCID: PMC9762221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Posterior fossa lesions can occur in patients of all ages. Patients present with subtle findings of hearing loss, tinnitus, headache, cranial neuropathies, imbalance, vertigo, nausea, and vomiting depending on the location and type of lesion. The presentation can be particularly insidious as the most common symptom is slowly progressive hearing loss. Posterior fossa lesions should be included in the differential diagnosis for patients with this presentation and appropriate audiologic testing and imaging should be performed. Management involves collaboration between multiple subspecialties and has evolved significantly over the years leading to increased patient involvement and improved outcomes.
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Affiliation(s)
- Haley N Bray
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Joshua M Sappington
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
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Matsumoto N, Kashio A, Yoshida M, Kondo K, Miyamoto S, Okazaki M, Ikemura M, Ushiku T, Yamasoba T. Cholesterol granuloma in facial nerve canal presenting with facial nerve paralysis. Auris Nasus Larynx 2022:S0385-8146(22)00210-3. [DOI: 10.1016/j.anl.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/14/2022] [Accepted: 09/14/2022] [Indexed: 11/05/2022]
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Maza G, Omar AMM, Subramaniam S, Otto BA, Prevedello DM, Carrau RL. Modified endoscopic endonasal approach with a minimally invasive transoral approach-an adjunct to infrapetrous approaches. Laryngoscope 2018; 129:339-343. [PMID: 30408171 DOI: 10.1002/lary.27469] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate the potential of a minimally invasive transoral-transpalatal approach (MITA) to the retrocarotid petrous apex, as an adjunct to endoscopic endonasal approaches (EEAs). STUDY DESIGN Cadaver study. METHODS Five cadaveric specimens were dissected raising an inverted U-shaped palatal mucoperiosteal flap, and drilling a rectangular palatotomy (between the greater palatine foramens, and just anterior to the palatine aponeurosis). This allowed a transpterygoid EEA with cross-court access (contralateral line of sight), followed by an extradural clivectomy that exposed the petroclival junction bilaterally. Surgical targets were marked on the posterior and medial surface of the petrous internal carotid artery (ICA), at its anterior genu, midhorizontal portion, and posterior genu. For each target and approach, the surgical freedom and angles of approach (in the horizontal and vertical planes) were calculated and statistically compared. RESULTS Compared to EEA, the MITA resulted in greater surgical freedom for all targets, with the highest values at the anterior genu (1,661.37 mm2 vs. 312.76 mm2 , P <.001), and maintaining superiority in this regard all the way to the posterior genu (847.84 mm3 vs. 138.91 mm3 , P < .005). MITA also offered greater angles of approach for all targets. CONCLUSIONS This study suggests that the MITA may be indicated to supplement the exposure provided by a transpterygoid EEA. This technique, associated with low potential morbidity, offers an alternative to internal carotid lateralization while managing extradural lesions that are adjacent to the petrous ICA. LEVEL OF EVIDENCE NA Laryngoscope, 129:339-343, 2019.
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Affiliation(s)
- Guillermo Maza
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, U.S.A
| | - Ali M Moustafa Omar
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, U.S.A
| | - Somasundram Subramaniam
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, U.S.A
| | - Bradley A Otto
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, U.S.A.,Department of Neurosurgery, The Ohio State University, Columbus, Ohio, U.S.A
| | - Daniel M Prevedello
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, U.S.A.,Department of Neurosurgery, The Ohio State University, Columbus, Ohio, U.S.A
| | - Ricardo L Carrau
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, U.S.A.,Department of Neurosurgery, The Ohio State University, Columbus, Ohio, U.S.A
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Banaama S, Stokroos R, Yakkioui Y, van Overbeeke J, Temel Y. A novel drainage approach in patients with cholesterol granuloma: From petrous apex to mastoid air cell. Surg Neurol Int 2017; 8:196. [PMID: 28904823 PMCID: PMC5590406 DOI: 10.4103/sni.sni_106_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/09/2017] [Indexed: 11/05/2022] Open
Abstract
Background: Cholesterol granulomas (CG) of the petrous apex (CGPA) are benign lesions that have high recurrence rates after surgical intervention. We describe the use of a robust silicon drain between the petrous apex and mastoid air cells to allow constant aeration of the lesion for preventing recurrence. Case Description: A retrospective analysis was performed using the data of four patients treated at the Maastricht University Medical Centre between 2014 and 2016. Using the middle fossa approach, the petrous apex was reached, the cyst was opened, and the content aspirated. Subsequently, a robust silicon drain was placed between the cyst and mastoid air cell system. The outcome measures were clinical improvement of the symptoms and radiological parameters. The patients were female (n = 2) and male (n = 2) with an age range between 33 and 53 years at the time of the operation. Computed tomography and magnetic resonance imaging scans were used to confirm CG diagnosis. The most common presenting symptoms in our population were diplopia and headaches. The symptoms improved after surgery and there were no complications. Thus far, no recurrence has been observed and imaging shows aeration in the lesion area. Conclusion: The use of a robust drain seems to be an effective, safe, and feasible option to prevent recurrences in patients with CG.
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Affiliation(s)
- Saeed Banaama
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robert Stokroos
- Department of Nose and Throat/Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Youssef Yakkioui
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jacobus van Overbeeke
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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Bruchhage KL, Wollenberg B, Leichtle A. Transsphenoidal and infralabyrinthine approach of the petrous apex cholesterol granuloma. Eur Arch Otorhinolaryngol 2017; 274:2749-2756. [PMID: 28474189 DOI: 10.1007/s00405-017-4593-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/19/2017] [Indexed: 10/19/2022]
Abstract
Space-demanding or destructive changes in the petrous bone are often challenging differential diagnosis. Cholesterol granulomas of the petrous apex can clinically present in a combination of hearing loss, vertigo, tinnitus, chronic cephalgia, impairment of facial nerve function, neuralgic pain of the nervus trigeminus, or manifest diplopia by the nerve palsy of the nervus abducens. CT-morphologically cholesterol granulomas appear as soft-tissue density masses, which may display a discrete rim after intravenous administration of a contrast agent. The MRI, T1 as well as T2-weighted images show a strong signal in the area of the lesion. Depending on the individual anatomical conditions, the surgical access must be carefully chosen between transsphenoidal, transtemporal, infracochlear/-labyrinthine, or translabyrinthine. Here, we present the transsphenoidal and translabyrinthine access for the excision of cholesterol granulomas of the petrous apex. The different accesses are compared using a neuro-navigation-supported surgical technique with respect to its complications, drainage possibilities, outcomes, and recurrence of symptoms.
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Affiliation(s)
- Karl-Ludwig Bruchhage
- Department of Otolaryngology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Barbara Wollenberg
- Department of Otolaryngology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Anke Leichtle
- Department of Otolaryngology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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Roemer S, Maeder P, Daniel RT, Kawasaki A. Sixth Nerve Palsy from Cholesterol Granuloma of the Petrous Apex. Front Neurol 2017; 8:48. [PMID: 28261154 PMCID: PMC5309254 DOI: 10.3389/fneur.2017.00048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 02/01/2017] [Indexed: 12/02/2022] Open
Abstract
Herein, we report a patient who had an isolated sixth nerve palsy due to a petrous apex cholesterol granuloma. The sixth nerve palsy appeared acutely and then spontaneously resolved over several months, initially suggesting a microvascular origin of the palsy. Subsequent recurrences of the palsy indicated a different pathophysiologic etiology and MRI revealed the lesion at the petrous apex. Surgical resection improved the compressive effect of the lesion at Dorello’s canal and clinical improvement was observed. A relapsing–remitting sixth nerve palsy is an unusual presentation of this rare lesion.
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Affiliation(s)
- Ségolène Roemer
- Department of Ophthalmology, University of Lausanne, Jules-Gonin Eye Hospital Fondation Asile des aveugles, Lausanne, Switzerland
| | - Philippe Maeder
- Department of Radiology, University of Lausanne, Lausanne University Hospital, Lausanne, Switzerland
| | - Roy Thomas Daniel
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Lausanne, Lausanne University Hospital, Lausanne, Switzerland
| | - Aki Kawasaki
- Department of Ophthalmology, University of Lausanne, Jules-Gonin Eye Hospital Fondation Asile des aveugles, Lausanne, Switzerland
- *Correspondence: Aki Kawasaki,
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Abstract
OBJECTIVE Five large petrous apex lesions, 4 cholesterol granulomas and 1 cholesteatoma, were managed with a combination of microsurgical and endoscopic techniques. STUDY DESIGN AND SETTING Retrospective review of clinical experience in an academic medical center. Traditional microsurgical approaches, infracochlear and/or retrofacial, were used in all cases, followed by endoscopic examination and debridement of the interior of the cysts. In all cases residual disease or fibrous septae within the cysts were found endoscopically that were not evident through use of the operating microscope. RESULTS In all cases, the lesions were successfully managed without operative complications. CONCLUSIONS The addition of endoscopic visualization to traditional microsurgical approaches allowed exposure of recesses within the lesions, removal of debris and inspissated secretions, and identification and removal of septae and fibrous bands within the petrous apex lesions that would not have been identified with the operating microscope alone. No surgical or postsurgical complications occurred in any of the cases, including facial weakness, hearing loss, or cerebrospinal fluid (CSF) leak.
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Affiliation(s)
- Douglas E Mattox
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Usefulness of image guidance in the surgical treatment of petrous apex cholesterol granuloma. Case Rep Otolaryngol 2013; 2013:257263. [PMID: 24251056 PMCID: PMC3819795 DOI: 10.1155/2013/257263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Accepted: 09/18/2013] [Indexed: 11/18/2022] Open
Abstract
The petrous apex is a pyramid-shaped structure, located medial to the inner ear and the intrapetrous segment of the internal carotid artery. Lesions of the petrous apex can be surgically treated through different surgical routes. Because of the important neurovascular structures located inside the temporal bone, anatomical 3D knowledge is paramount. For this reason, image-guided surgery could represent a useful tool. We report the case of a young woman who came to our observation for a trigeminal neuralgia due to a petrous apex cholesterol granuloma. The lesion was treated through the placement of a drainage tube via an infracochlear approach, with the aid of neuronavigation and intraoperative MRI. Preoperative CT scan images and intraoperative MRI images were fused for surgical planning. The accuracy of the neuronavigation system has proved to be good, and the safety of the procedure was enhanced. Therefore, neuronavigation and intraoperative MRI, though not available in all neurootological centres, should be considered useful tools in these challenging procedures.
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Kusumi M, Fukushima T, Mehta AI, Cunningham CD, Friedman AH, Fujii K. Middle fossa approach for total resection of petrous apex cholesterol granulomas: use of vascularized galeofascial flap preventing recurrence. Neurosurgery 2013; 72:77-86; discussion 86. [PMID: 22986599 DOI: 10.1227/neu.0b013e3182724354] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cholesterol granulomas (CGs) of the petrous apex (PA) are rare, benign, expanding lesions. Surgical treatment is recommended for patients with symptomatic disease; however, the optimal surgical procedure is still controversial due to high recurrence rates. The main treatment strategy is divided into drainage and complete resection. OBJECTIVE We advocate radical resection of the lesion by the middle fossa approach and reconstruction with a vascularized galeofascial flap. METHODS A 10-year retrospective case review of 17 patients undergoing surgical treatment of PA CGs between 2000 and 2010 was undertaken. Operative outcomes and surgical complications were analyzed. In addition, our operative method and the related anatomy are described from cadaveric dissections. RESULTS All but 1 patient was operated on via a middle fossa approach. Using the middle fossa approach, radical resection of all PA CGs was achieved with obliteration of the cyst cavity using a vascularized flap. Important surrounding structures included the internal auditory canal, cochlea, petrous carotid artery, and abducens nerve. There was 1 death caused by internal carotid artery occlusion. No other major complications or cranial nerve deficits occurred postoperatively. Clinical recurrence occurred in 1 patient (5.9%). CONCLUSION Our technique of radical resection and reconstruction with a vascularized flap has the advantage of being less invasive with less cosmetic deformity and allows preservation of cranial nerve function with a low recurrence rate. Knowledge of the surgical anatomy and the characteristics of CG is prudent because important neurovascular structures may be exposed behind the CG wall due to bony erosion.
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Affiliation(s)
- Mari Kusumi
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA.
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McLaughlin N, Kelly DF, Prevedello DM, Shahlaie K, Carrau RL, Kassam AB. Endoscopic endonasal management of recurrent petrous apex cholesterol granuloma. J Neurol Surg B Skull Base 2013; 73:190-6. [PMID: 23730548 DOI: 10.1055/s-0032-1312706] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2010] [Accepted: 11/15/2010] [Indexed: 10/28/2022] Open
Abstract
Introduction Petrous apex cholesterol granulomas (PACGs) are uncommon lesions. Recurrence following transcranial or endonasal approaches to aerate the cyst occurs in up to 60% of cases. We describe the technical nuances pertinent to the endonasal endoscopic management of a recurrent symptomatic PACG and review the literature. Results A 19-year-old woman presented with a recurrent abducens nerve paresis. Four months prior, she underwent an endonasal transsphenoidal surgery (TSS) for drainage of a symptomatic PACG. Current imaging documented recurrence of the right PACG. Transsphenoidal and infrapetrous approaches were performed to obtain a wider bony opening along the petrous apex and drain the cyst. A Doyle splint was inserted into the cyst's cavity and extended out into the sphenoid sinus, maintaining patency during the healing process. Three months after surgery, the splint was removed endoscopically, allowing visualization of a patent cylindrical communication between both aerated cavities. The patient remains symptom-free and recurrence-free. Conclusion Endoscopic endonasal surgery must be adapted to manage a recurrent PACG. A TSS may not be sufficient. An infrapetrous approach with wider bony opening, extensive removal of the cyst's anterior wall, and the use of a stent are indicated for the treatment of recurrent PACG and to prevent recurrences.
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Affiliation(s)
- Nancy McLaughlin
- Brain Tumor Center, John Wayne Cancer Institute of Saint John's Health Center, Santa Monica, California, United States
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Freigang S, Ampenberger F, Spohn G, Heer S, Shamshiev AT, Kisielow J, Hersberger M, Yamamoto M, Bachmann MF, Kopf M. Nrf2 is essential for cholesterol crystal-induced inflammasome activation and exacerbation of atherosclerosis. Eur J Immunol 2011; 41:2040-51. [PMID: 21484785 DOI: 10.1002/eji.201041316] [Citation(s) in RCA: 232] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 03/13/2011] [Accepted: 04/08/2011] [Indexed: 12/18/2022]
Abstract
Oxidative stress and inflammation--two components of the natural host response to injury--constitute important etiologic factors in atherogenesis. The pro-inflammatory cytokine interleukin (IL)-1 significantly enhances atherosclerosis, however, the molecular mechanisms of IL-1 induction within the artery wall remain poorly understood. Here we have identified the oxidative stress-responsive transcription factor NF-E2-related 2 (Nrf2) as an essential positive regulator of inflammasome activation and IL-1-mediated vascular inflammation. We show that cholesterol crystals, which accumulate in atherosclerotic plaques, represent an endogenous danger signal that activates Nrf2 and the NLRP3 inflammasome. The resulting vigorous IL-1 response critically depended on expression of Nrf2, and Nrf2-deficient apolipoprotein E (Apoe)-/- mice were highly protected against diet-induced atherogenesis. Importantly, therapeutic neutralization of IL-1α and IL-1β reduced atherosclerosis in Nrf2+/- Apoe-/- but not in Nrf2-/- Apoe-/- mice, suggesting that the pro-atherogenic effect of Nrf2-signaling was primarily mediated by its permissive role in IL-1 production. Our studies demonstrate a role for Nrf2 in inflammasome activation, and identify cholesterol crystals as disease-relevant triggers of the NLRP3 inflammasome and potent pro-atherogenic cytokine responses. These findings suggest a common pathway through which oxidative stress and metabolic danger signals converge and mutually perpetuate the chronic vascular inflammation that drives atherosclerosis.
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Affiliation(s)
- Stefan Freigang
- Molecular Biomedicine, Institute of Integrative Biology, ETH Zurich, Schlieren, Switzerland.
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McLaughlin N, Kelly DF, Prevedello DM, Shahlaie K, Carrau RL, Kassam AB. Endoscopic endonasal management of recurrent petrous apex cholesterol granuloma. SKULL BASE REPORTS 2011; 1:27-32. [PMID: 23984199 PMCID: PMC3743582 DOI: 10.1055/s-0031-1275253] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2010] [Accepted: 11/15/2010] [Indexed: 11/19/2022]
Abstract
Petrous apex cholesterol granulomas (PACG) are uncommon lesions. Recurrence following transcranial or endonasal approaches to aerate the cyst occurs in up to 60% of cases. We describe the technical nuances pertinent to the endonasal endoscopic management of a recurrent symptomatic PACG and review the literature. A 19-year-old woman presented with a recurrent right abducens nerve paresis. Four months prior, she underwent an endonasal transsphenoidal surgery (TSS) for drainage of a symptomatic PACG. Current imaging documented recurrence of the right PACG. Transsphenoidal and infrapetrous approaches were performed to obtain a wider bony opening along the petrous apex and drain the cyst. A Doyle splint was inserted into the cyst's cavity and extended out into the sphenoid, maintaining patency during the healing process. Three months after surgery, the splint was removed endoscopically, allowing visualization of a patent cylindrical communication between both aerated cavities. The patient remains symptom- and recurrence-free. Endoscopic endonasal surgery must be adapted to manage recurrent PACG. A TSS may not be sufficient. An infrapetrous approach with wider bony opening, extensive removal of the cyst's anterior wall, and use of a stent are indicated for the treatment of recurrent PACG and to prevent recurrences.
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Affiliation(s)
- Nancy McLaughlin
- Brain Tumor Center, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California
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Nikolaidis V, Malliari H, Psifidis D, Metaxas S. Cholesterol granuloma presenting as a mass obstructing the external ear canal. BMC EAR, NOSE, AND THROAT DISORDERS 2010; 10:4. [PMID: 20367883 PMCID: PMC2853487 DOI: 10.1186/1472-6815-10-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Accepted: 04/05/2010] [Indexed: 11/10/2022]
Abstract
BACKGROUND Cholesterol granuloma (CG) may involve the middle ear, the mastoid bone and the petrous apex. However, CG presenting as a mass obstructing the external ear canal (EEC) is relatively rare and it can be a diagnostic challenge. CASE PRESENTATION We report a case of a CG occupying the mastoid antrum and presenting as a mass into the EEC. Temporal bone computerized tomography showed a soft tissue mass which eroded the posterior-superior bony wall of the EEC. On magnetic resonance imaging, the mass revealed a high signal on both T1 and T2-weighted images. The CG was removed by a mastoidectomy procedure and the histopathologic report confirmed the diagnosis of CG. A type III tympanoplasty was performed. CONCLUSIONS The postoperative course was uneventful.
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Affiliation(s)
- Vasilios Nikolaidis
- 2nd Department of Otolaryngology, Aristotle University,, Papageorgiou G,H,, Thessaloniki, Greece.
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Abstract
AIM OF THE STUDY We report 2 cases (52 and 29-year-old men) of CG in the petrous apex we treated in 2004-2006. We also review the literature and discus the mechanism of development of CG and the treatment of this lesion. MATERIAL AND METHODS Cholesterol granuloma (CG) is a chronic inflammatory process with associated foreign body reaction to hemorrhage-related cholesterol crystals. Although CG is found in various organs the temporal bone is the most common site of detection. Numerous ethiopathological hypotheses have been proposed but most authorities support the concept of air cell tract blockage in well pneumatized petrous apex. Obstruction of the air cells leads to rupture of blood vessels and hemorrhage. Red blood cell degradation into cholesterol crystals produces a foreign body giant-cell reaction with progressive accumulation of typical brownish glistening fluid. Clinically, this lesion can produce sensorineural hearing loss, tinnitus, hemifacial spasm, facial numbness and trigeminal neuralgia. Cholesteatoma is the main lesion to distinguish from CG. On MRI studies, CG appears with a high signal on both T1- and T2-weighted sequences, cholesteatoma appear bright only on T2-weighted ones. Goal of the surgery is to create a drainage and ventilation of the affected area to prevent recurrence. Several alternative approaches to the petrous apex have been described. RESULTS 12-18 months follow up shows no clinical signs of recurrence.
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Abstract
PURPOSE OF REVIEW This paper reviews the literature relating to the pathogenesis, diagnosis and management of petrous apex cholesterol granulomas. RECENT DEVELOPMENTS Diagnosis of cholesterol granulomas can be challenging due to the rarity of this surgical condition and similarities to other petrous apex pathology. Recent literature reports novel locations of cholesterol granulomas, provides support for a new theory of pathogenesis, describes additional cases of endoscopic approaches to excision, and evaluates the efficacy of stenting to prevent recurrence of the lesion. SUMMARY Cholesterol granulomas of the petrous apex are significant due to their similarity to other petrous apex lesions, their adverse effect on cranial nerves and their challenging surgical location. These lesions are now believed to be an inflammatory reaction to the by-products of eroded marrow cavities in the temporal bone. The ideal surgical approach takes into account the hearing status of the patient and lesion location and may include the endoscopic transsphenoid, transmastoid, infralabyrinthine, middle fossa, and transotic approaches. Lesions should be excised, drained, and stented with the largest diameter silicone stent possible.
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Affiliation(s)
- Mark C Royer
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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Mendonça R, Peron CS, Stefani MA, Gallo P. Cerebral cholesterol granuloma: case report. ARQUIVOS DE NEURO-PSIQUIATRIA 2007; 65:540-1. [PMID: 17665033 DOI: 10.1590/s0004-282x2007000300036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2006] [Accepted: 03/13/2007] [Indexed: 11/21/2022]
Abstract
Intracranial cholesterol granulomas are rare lesions, and have been registered in petrous apex region. The presence of an intracerebral cholesterol granuloma is an uncommun event. We report the case of a 20-years-old woman who undergone craniotomy for resection of a temporal mass. Pathologic examination show a cholesterol granuloma.
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Affiliation(s)
- Rodrigo Mendonça
- Serviço de Neurocirurgia do Hospital Cristo Redentor, Porto Alegre RS, Brazil
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Sincoff EH, Liu JK, Matsen L, Dogan A, Kim I, McMenomey SO, Delashaw JB. A novel treatment approach to cholesterol granulomas. J Neurosurg 2007; 107:446-50. [PMID: 17695405 DOI: 10.3171/jns-07/08/0446] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓ The authors report a novel technique for the treatment of cholesterol granulomas. An extradural middle fossa approach was used to access the granuloma, with drainage through silastic tubes into the sphenoid sinus via the anteromedial triangle between V1 and V2.
Cholesterol granulomas occur when the normal aeration and drainage of temporal bone air cells is occluded, resulting in vacuum formation and transudation of blood into the air cells. This process results in anaerobic breakdown of the blood with resulting cholesterol crystal formation and an inflammatory reaction. Traditional treatment of this lesion involves extensive drilling of the temporal bone to drain the granuloma cyst and establish a drainage tract into the middle ear. Such drainage procedures can be time consuming and difficult, and potentially involve structural damage to the inner ear and facial nerve. An extradural middle fossa approach provides easy access to the granuloma and anterior petrous bone entry into the granuloma for resection. Granuloma drainage is then achieved using shunt tubing in the sphenoid sinus via a small hole in the anteromedial triangle between V1 and V2.
Five patients with symptomatic cholesterol granuloma were treated without complication using this novel extradural middle fossa approach. One patient required reoperation 1-year postoperatively for cyst regrowth and occlusion of the drainage tube. At the 5-year follow-up examination, no patient reported recurrent symptoms.
Extradural middle fossa craniotomy and silastic tube drainage into the sphenoid sinus is a viable alternative method for treatment of cholesterol granuloma.
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Affiliation(s)
- Eric H Sincoff
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon 97239, USA
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Löwenheim H, Koerbel A, Ebner FH, Kumagami H, Ernemann U, Tatagiba M. Differentiating imaging findings in primary and secondary tumors of the jugular foramen. Neurosurg Rev 2005; 29:1-11; discussion 12-13. [PMID: 16283211 DOI: 10.1007/s10143-005-0420-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2005] [Accepted: 08/28/2005] [Indexed: 10/25/2022]
Abstract
The preoperative diagnosis of a jugular foramen tumor may be challenging, since a large variety of unusual lesions may be located in this region. These tumors may be classified as primary lesions (which are located in the jugular foramen or extend from the jugular foramen into the surrounding structures) and as secondary lesions (that extend from the surrounding structures into the jugular foramen). Primary tumors include glomus jugulare tumors, schwannomas, meningiomas and peripheral primitive neuroectodermal tumors, while secondary tumors comprise chordomas, chondrosarcomas, chondroblastomas, giant-cell tumors, cholesterol granulomas, giant cholesterol cyst, endolymphatic sac tumors, reactive myofibroblastic tumors, temporal bone carcinomas and metastases. Accurate preoperative radiological suspicion is of great value for preoperative patient counseling and has a direct impact on the surgical planning in these cases. The present study describes and discusses the main differentiating imaging features of lesions involving the jugular foramen, whose accurate preoperative radiological evaluation is essential for proper surgical planning.
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Affiliation(s)
- Hubert Löwenheim
- Department of Otolaryngology-Head and Neck Surgery, University of Tuebingen, Tuebingen, Germany
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Affiliation(s)
- D J Verret
- Department of Otolaryngology, Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9035, USA
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Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 2005. [DOI: 10.3171/foc.2005.19.1.7] [Citation(s) in RCA: 357] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ObjectThe middle third of the clivus and the region around the petrous internal carotid artery (ICA) is a difficult area of the skull base in terms of access. This is a deep area rich with critical neurovascular structures, which is often host to typical skull base diseases. Expanded endoscopic endonasal approaches offer a potential option for accessing this difficult region. The objective of this paper was to establish the clinical feasibility of gaining access to the paraclival space in the region of the middle third of the clivus, to provide a practical modular and clinically applicable classification, and to describe the relevant critical surgical anatomy for each module.MethodsThe anatomical organization of the region around the petrous ICA, cavernous sinus, and middle clivus is presented, with approaches divided into zones. In an accompanying paper in this issue by Cavallo, et al., the anatomy of the pterygopalatine fossa is presented; this was observed through cadaveric dissection for which an expanded endonasal approach was used. In the current paper the authors translate the aforementioned anatomical study to provide a clinically applicable categorization of the endonasal approach to the region around the petrous ICA. A series of zones inferior and superior to the petrous ICA are described, with an illustrative case presented for each region.ConclusionsThe expanded endonasal approach is a feasible approach to the middle third of the clivus, petrous ICA, cavernous sinus, and medial infratemporal fossa in cases in which the lesion is located centrally, with neurovascular structures displaced laterally.
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