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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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Singh AK, Patel BK, Darshan HR, Anand B, Singh A, Biradar H, George T, Easwer HV, Nair P. Endoscopic Transpterygoid Corridor for Petroclival Tumors: Case Series and Technical Nuances. Neurol India 2023; 71:1159-1166. [PMID: 38174451 DOI: 10.4103/0028-3886.391346] [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] [Indexed: 01/05/2024]
Abstract
Background The petroclival area is a technically challenging region to operate owing to the proximity of the internal carotid artery (ICA) and the need to obtain gross total excision of tumors in this area as they are often resistant to radiotherapy. Objective We present our experience with the endonasal endoscopic transpterygoid approach in managing tumors of the petroclival region and discuss various operative nuances for safer resection. Materials and Methods A retrospective study of all consecutive cases of lesions occupying the petroclival region that were operated via endonasal endoscopic transpterygoid approach at our center between January 2016 and December 2021 was performed. Results The study included 14 cases of lesions occupying the petroclival region. Gross total resection by intraoperative observation was achieved in 10 patients, near total decompression was performed in two patients, and the remaining two patients underwent marsupialization of lesion. Postoperatively, one patient had right Lower motor neuron (LMN) facial nerve palsy and one patient required surgery for Cerebrospinal fluid (CSF) rhinorrhea on postoperative day 8. The mean duration of follow-up was 13.8 ± 16.6 months (range: 2-59 months). Four of six patients with visual symptoms on presentation reported improvement in vision, and the other two patients had a stable vision on follow-up. Two patients received radiotherapy postsurgery. No mortality was noted. Conclusion The extended endonasal endoscopic transpterygoid approach can be safely and efficiently used for petroclival lesions. Very sound knowledge of anatomical relationship, use of intraoperative image guidance to avoid injury to ICA, and multilayer reconstruction with a vascularized nasoseptal flap are required to optimize the clinical outcome.
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Affiliation(s)
- Arvind K Singh
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Biren K Patel
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Hirisave Ravikumar Darshan
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Binu Anand
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Ajit Singh
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Harshvardhan Biradar
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Tobin George
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Harihara Venkat Easwer
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Prakash Nair
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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3
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Corvino S, Guizzardi G, Sacco M, Corrivetti F, Bove I, Enseñat J, Colamaria A, Prats-Galino A, Solari D, Cavallo LM, Di Somma A, de Notaris M. The feasibility of three port endonasal, transorbital, and sublabial approach to the petroclival region: neurosurgical audit and multiportal anatomic quantitative investigation. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05498-6. [PMID: 36752892 DOI: 10.1007/s00701-023-05498-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/02/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE The petroclival region represents the "Achille's heel" for the neurosurgeons. Many ventral endoscopic routes to this region, mainly performed as isolated, have been described. The aim of the present study is to verify the feasibility of a modular, combined, multiportal approach to the petroclival region to overcome the limits of a single approach, in terms of exposure and working areas, brain retraction and manipulation of neurovascular structures. METHODS Four cadaver heads (8 sides) underwent endoscopic endonasal transclival, transorbital superior eyelid and contralateral sublabial transmaxillary-Caldwell-Luc approaches, to the petroclival region. CT scans were obtained before and after each approach to rigorously separate the contribution of each osteotomy and subsequentially to build a comprehensive 3D model of the progressively enlarged working area after each step. RESULTS The addition of the contralateral transmaxillary and transorbital corridors to the extended endoscopic endonasal transclival in a combined multiportal approach provides complementary paramedian trajectories to overcome the natural barrier represented by the parasellar and paraclival segments of the internal carotid artery, resulting in significantly greater area of exposure than a pure endonasal midline route (8,77 cm2 and 11,14 cm2 vs 4,68 cm2 and 5,83cm2, extradural and intradural, respectively). CONCLUSION The use of different endoscopic "head-on" trajectories can be combined in a wider multiportal extended approach to improve the ventral route to the most inaccessible petroclival regions. Finally, by combining these approaches and reiterating the importance of multiportal strategy, we quantitatively demonstrate the possibility to reach "far away" paramedian petroclival targets while preserving the neurovascular structures.
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Affiliation(s)
- Sergio Corvino
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Giulia Guizzardi
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Matteo Sacco
- Department of Neurosurgery, "Riuniti" Hospital, Foggia, Italy
| | - Francesco Corrivetti
- Department of Neurosurgery, San Luca Hospital, Vallo Della Lucania, Salerno, Italy.,Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy
| | - Ilaria Bove
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Joaquim Enseñat
- Departments of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Alberto Prats-Galino
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, Naples, Italy
| | - Alberto Di Somma
- Laboratory of Surgical Neuroanatomy, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain. .,Departments of Neurological Surgery, Hospital Clínic de Barcelona, Barcelona, Spain.
| | - Matteo de Notaris
- Laboratory of Neuroscience, EBRIS Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy.,Neurosurgery Operative Unit, Department of Neuroscience, "San Pio" Hospital, Benevento, Italy
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A Rare Case of a Primary Leiomyoma of the Clivus in an Immunocompetent Patient and a Review of the Literature Regarding Clival Lesions. Diagnostics (Basel) 2022; 13:diagnostics13010009. [PMID: 36611301 PMCID: PMC9818954 DOI: 10.3390/diagnostics13010009] [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: 11/14/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Leiomyomas are common lesions that are usually located in the genitourinary and gastrointestinal tracts. Primary leiomyomas at the skull base are uncommon. They are composed of well-differentiated smooth muscle cells without cellular atypia. The diagnosis of a leiomyoma has to be confirmed by immunohistochemistry. The tumor tissue is immunoreactive for SMA, S100 and cytokeratin. Leiomyomas mainly occur in immunocompromised patients. Most tumor tissues are positive for EBV. The presented case is that of a 56-year-old immunocompetent woman with a tumor on the clivus. The radiological images suggested chordoma or fibrous dysplasia. Transnasal transsphenoidal surgery was performed. The tumor tissue consisted of well-differentiated smooth muscle cells with elongated nuclei. Immunohistochemistry revealed a positive reaction for desmin, SMA and h-Caldesmon and a negative reaction for S100, beta-catenin, PGR and Ki67. The leiomyoma diagnosis was subsequently established. To the best of our knowledge, the case of a primary leiomyoma on the clivus of an immunocompetent patient is the first to be described. We also extensively reviewed the literature on the immunohistopathological and radiological differential diagnosis of clival lesions.
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Almeida JP, Sreenath SB, de Andrade EJ, Recinos PF, Woodard TD, Kshettry VR. Endoscopic Transpterygoid Transcavernous Approach for Resection of a Petroclival Chondrosarcoma: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e60-e61. [PMID: 35726942 DOI: 10.1227/ons.0000000000000222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 01/26/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Joao Paulo Almeida
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain, Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida (Current Affiliation), USA
| | - Satyan B Sreenath
- Department of Otolaryngology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erion J de Andrade
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain, Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pablo F Recinos
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain, Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Troy D Woodard
- Department of Otolaryngology, Sinus, and Skull Base Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Minimally Invasive Cranial Base and Pituitary Surgery, Rosa Ella Burkhardt Brain, Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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6
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Martinez-Perez R, Kortz MW, Florez-Perdomo W, Ung TH, Youssef AS. Endocrinological outcomes after transcranial resection of tuberculum sellae meningiomas: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:1965-1975. [PMID: 35149901 DOI: 10.1007/s10143-022-01744-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/03/2022] [Accepted: 01/19/2022] [Indexed: 11/26/2022]
Abstract
Tuberculum sellae meningiomas (TSMs) arise from the anterior skull base. Endocrine status after TSM resection is an important determinant of quality of life. We sought to better characterize the risk of postoperative endocrinopathy for patients with TSM undergoing open transcranial approach (TCA) microsurgical resection. A systematic review was conducted following MOOSE and PRISMA guidelines. Results were screened against predefined criteria, which included studies evaluating endocrinopathy rates after open transcranial microsurgery for TSM. Outcome incidence was calculated using random-effect meta-analysis of proportions. Eight studies met the inclusion criteria, comprising 406 patients. The average age of the cohort was 52.2 years, and a majority (70%) of the patients were female. The pooled incidence of postoperative transient diabetes insipidus (DI) was 7.5% (95% CI 2.9-12%; p = 0.001; I2 = 75.9%) and permanent DI was 1.6% (95% CI 0.3-2.7%; p = 0.01; I2 = 0%). The pooled rate of postoperative hypopituitarism was 3.6% (95% CI 1.6-5.7%; p < 0.001; I2 = 22.2%), while the incidence of hyperprolactinemia was 1.3% (95% CI 0.1 = 2.6%; p = 0.036; I2 = 8.74%). The incidence of SIADH was 4% in one study but was not included in the meta-analysis. Endocrinopathy after TSM microsurgical resection is rare, but the available studies' poor quality of evidence and inconsistent methodology may reflect that it is underreported in the literature. Nevertheless, clinicians should consider the risk of hormonal impairment and counsel their patients accordingly when selecting a TCA for these lesions.
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Affiliation(s)
- Rafael Martinez-Perez
- Departments of Neurosurgery, Department of Neurosurgery and Neuroscience Institute, Geisinger Health System and Geisinger Commonwealth School of Medicine, 1000 East Mountain Boulevard, Wilkes Barre, PA, 18711, USA.
| | - Michael W Kortz
- Department of Neurological Surgery, University of Colorado, Denver, CO, USA
| | - William Florez-Perdomo
- Department of Medicine, Concejo Latinoamericano de Neurointensivismo-CLaNi, Cartagena, Colombia
| | - Timothy H Ung
- Department of Otolaryngology, University of Colorado, Denver, CO, USA
| | - A Samy Youssef
- Department of Neurological Surgery, University of Colorado, Denver, CO, USA.
- Department of Otolaryngology, University of Colorado, Denver, CO, USA.
- Department of Neurosurgery, University of Colorado School of Medicine, 1635 Aurora Ct, 4th Floor, Denver, CO, 80045, USA.
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7
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Mattavelli D, Fiorentino A, Tengattini F, Colpani A, Agnelli S, Buffoli B, Ravanelli M, Ferrari M, Schreiber A, Rampinelli V, Taboni S, Verzeletti V, Deganello A, Rodella LF, Maroldi R, Ceretti E, Sartore L, Piazza C, Fontanella MM, Nicolai P, Doglietto F. Additive Manufacturing for Personalized Skull Base Reconstruction in Endoscopic Transclival Surgery: A Proof-of-Concept Study. World Neurosurg 2021; 155:e439-e452. [PMID: 34450324 DOI: 10.1016/j.wneu.2021.08.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endoscopic transnasal transclival intradural surgery is limited by a high postoperative cerebrospinal fluid leak rate. The aim of this study was to investigate the role of three-dimensional printing to create a personalized, rigid scaffold for clival reconstruction. METHODS Two different types of clivectomy were performed in 5 specimens with the aid of neuronavigation, and 11 clival reconstructions were simulated. They were repaired with polylactide, three-dimensional-printed scaffolds that were manually designed in a computer-aided environment based either on the real or on the predicted defect. Scaffolds were printed with a fused filament fabrication technique and different offsets. They were positioned and fixed either following the gasket seal technique or with screws. Postdissection radiological evaluation of scaffold position was performed in all cases. In 3 specimens, the cerebrospinal fluid leak pressure point was measured immediately after reconstruction. RESULTS The production process took approximately 30 hours. The designed scaffolds were satisfactory when no offset was added. Wings were added during the design to allow for screw positioning, but broke in 30% of cases. Radiological assessment documented maximal accuracy of scaffold positioning when the scaffold was created on the real defect; accuracy was satisfactory when the predicted clivectomy was performed under neuronavigation guidance. The cerebrospinal fluid leak pressure point was significantly higher when the scaffold was fixed with screws compared with the gasket technique. CONCLUSIONS In this preclinical setting, additive manufacturing allows the creation of customized scaffolds that are effective in reconstructing even large and geometrically complex clival defects.
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Affiliation(s)
- Davide Mattavelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Fiorentino
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Francesco Tengattini
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alessandro Colpani
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Silvia Agnelli
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Ravanelli
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ferrari
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Alberto Schreiber
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Vittorio Rampinelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Stefano Taboni
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Vincenzo Verzeletti
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Alberto Deganello
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Fabrizio Rodella
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Elisabetta Ceretti
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Luciana Sartore
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
| | - Cesare Piazza
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco M Fontanella
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Section of Otorhinolaryngology-Head and Neck Surgery, Department of Neurosciences, University of Padua, Padua, Italy
| | - Francesco Doglietto
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.
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8
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Pagella F, Ugolini S, Zoia C, Matti E, Carena P, Lizzio R, Benazzo M. Clivus pathologies from diagnosis to surgical multidisciplinary treatment. Review of the literature. ACTA ACUST UNITED AC 2021; 41:S42-S50. [PMID: 34060519 PMCID: PMC8172112 DOI: 10.14639/0392-100x-suppl.1-41-2021-04] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 01/09/2021] [Indexed: 11/25/2022]
Abstract
The Clivus is a bone that lies in a central position of the skull base, and it is a crucial point that splits and connects different anatomical compartments at the same time. There is significant variability of diseases involving the clivus, from neoplasms to non-neoplastic, inflammatory or traumatic lesions. Each of these is rare in frequency, and this heterogeneity contributes to yield the management even more challenging. Clival pathologies can be asymptomatic or have manifestations ranging from aspecific headache to cranial nerves palsies, till life-threatening complications as cerebrospinal fluid rhinorrhoea, meningitis or brain abscess. There isn’t an univocal endorsement among experts with regard to the best approaches to manage the clivus. The paths described are many, the main division is between the transclival and transcranial lateral approaches. We performed a review of the literature, thus highlighting how authors seem to suggest that the surgical approach shouldn’t be chosen aprioristically, but based on a patient centred analysis, considering the combination of multiple surgical corridors. From diagnosis to surgery and medical therapy, clival pathologies require a team of multidisciplinary experts to ensure the best standard of treatment and higher survival rate.
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Affiliation(s)
- Fabio Pagella
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.,Department of Otorhinolaryngology, University of Pavia, Italy
| | - Sara Ugolini
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.,Department of Otorhinolaryngology, University of Pavia, Italy
| | - Cesare Zoia
- Neurosurgery Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Elina Matti
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Paolo Carena
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Roberta Lizzio
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Marco Benazzo
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.,Department of Otorhinolaryngology, University of Pavia, Italy
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9
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Endoscopic Endonasal Approach for Clipping Anterior Communicating Artery Aneurysms From Cadaver Studies and Three-Dimensional Printed Models to a Clinical Case. J Craniofac Surg 2021; 32:2854-2858. [PMID: 34238881 DOI: 10.1097/scs.0000000000007848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Anterior communicating artery (ACoA) aneurysm is one of the most common intracranial aneurysms, and it is also the aneurysm with the highest rupture rate. With the improvement of endoscopic techniques, it is possible to use an endoscopic endonasal approach (EEA) to clip ACoA aneurysms. For further analysis of the EEA for clipping ACoA aneurysms, we used cadaver heads and three-dimensional (3D)-printed models to finish the anatomical study, and we finally selected 1 clinical case to complete the clipping through the EEA. MATERIALS AND METHODS We first collected 3 cadaver heads to simulate the EEA. Then, the imaging data of 29 real cases of ACoA aneurysm were collected, and the model of an aneurysm was prepared by 3D printing technology; then, the EEA was used to simulate the clipping of the aneurysm model. Finally, a clinical case with 2 ACoA aneurysms was selected to adopt the EEA for clipping. RESULTS Both the cadaver head and 3D-printed aneurysm model could simulate aneurysm clipping with the EEA. The clinical case of the selected ACoA aneurysm can successfully complete the clipping through the EEA. CONCLUSIONS 3D-printed models are a good method to study the anatomical characteristics of a surgical approach. For specially selected ACoA aneurysms, the EEA is relatively simple method that can be used to clip the aneurysm successfully. The EEA for clipping ACoA aneurysms is a useful complement to the current traditional craniotomy approaches and endovascular embolization.
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10
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Topczewski TE, Di Somma A, Culebras D, Reyes L, Torales J, Tercero A, Langdon C, Alobid I, Torne R, Roldan P, Prats-Galino A, Ensenat J. Endoscopic endonasal surgery to treat intrinsic brainstem lesions: correlation between anatomy and surgery. Rhinology 2021; 59:191-204. [PMID: 33346253 DOI: 10.4193/rhin20.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach (EEA) has been proposed as an alternative in the surgical removal of ventral brainstem lesions. However, the feasibility and limitations of this approach to treat such pathologies are still poorly understood. This study aimed to report our experience in five consecutive cases of intrinsic brainstem lesions that were managed via an EEA, as well as the specific anatomy of each case. METHODS All patients were treated in a single center by a multidisciplinary surgical team between 2015 and 2019. Before surgery, a dedicated anatomical analysis of the brainstem safe entry zone was performed, and proper surgical planning was carried out. Neurophysiological monitoring was used in all cases. Anatomical dissections were performed in three human cadaveric heads using 0° and 30° endoscopes, and specific 3D reconstructions were executed using Amira 3D software. RESULTS All lesions were located at the level of the ventral brainstem. Specifically, one mesencephalic cavernoma, two pontine ca- vernomas, one pontine gliomas, and one medullary diffuse midline glioma were reported. Cerebrospinal fluid leak was the major complication that occurred in one case (medullary diffuse midline glioma). From an anatomical standpoint, three main safe entry zones were used, namely the anterior mesencephalic zone (AMZ), the peritrigeminal zone (PTZ, used in two cases), and the olivar zone (OZ). Reviewing the literature, 17 cases of various brainstem lesions treated using an EEA were found. CONCLUSIONS To our knowledge, this was the first preliminary clinical series of intrinsic brainstem lesions treated via an EEA presented in the literature. The EEA can be considered a valid surgical alternative to traditional transcranial approaches to treat selected intra-axial brainstem lesions located at the level of the ventral brainstem. To achieve good results, surgery must involve comprehensive anatomical knowledge, meticulous preoperative surgical planning, and intraoperative neurophysiological moni- toring.
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Affiliation(s)
- T E Topczewski
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - A Di Somma
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain.,Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - D Culebras
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - L Reyes
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - J Torales
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - A Tercero
- Institut Clínic de Neurociències (ICN), Department of Neurology, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - C Langdon
- Rhinology Unit and Smell Clinic, Otorhinolaryngology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - I Alobid
- Rhinology Unit and Smell Clinic, Otorhinolaryngology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - R Torne
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - P Roldan
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
| | - A Prats-Galino
- Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - J Ensenat
- Institut Clínic de Neurociències (ICN), Department of Neurological Surgery, Hospital Clínic de Barcelona, Universidad de Barcelona, Barcelona, Spain
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Abstract
INTRODUCTION Since the early use of the endoscopic view for treating simple intrasellar pituitary adenomas, the skull base surgery has experienced an unprecedented revolution elevating the treatment of skull base lesions to the next level in proficiency and excellence of care. METHODS We have reviewed the preclinical and clinical evidence supporting the use of the endoscope in the treatment of skull base lesions. In this article, we aim to discuss and provide a wide view of the current indications and future perspectives of the endoscopic endonasal approaches (EEA) and of the endoscopic transcranial approaches. RESULTS As in the development of any other technique, EEA have gone through a transformation process from theoretical anatomic models to a pragmatic clinical use. Along the way, EEA have required several modifications, as well as pushbacks in the application of this technique in some indications. This process has resulted in the provision of an additional tool to the current surgical armamentarium that allows the skull base surgeon to face most challenging lesions along the skull base. CONCLUSIONS The judicious combination of transcranial and endoscopic-transnasal approaches warrants highest chances of achieving satisfactory tumors resection with a reduced risk of complications.
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12
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Özer Mİ, Kutlay AM, Durmaz MO, Kirik A, Yaşar S, Tehli Ö, Kural C, Temiz NÇ, Durmaz A, Ezgu MC, Daneyemez MK, Izci Y. Extended endonasal endoscopic approach for anterior midline skull base lesions. Clin Neurol Neurosurg 2020; 196:106024. [PMID: 32619902 DOI: 10.1016/j.clineuro.2020.106024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/15/2020] [Accepted: 06/14/2020] [Indexed: 11/29/2022]
Abstract
AIM In recent years, extended endoscopic endonasal approach (EEEA) has been used as an alternative to transcranial approaches in the treatment of anterior midline skull base lesions. We retrospectively reviewed our cases operated using this technique and compared the results with current literature. METHOD The data of 24 patients who were operated using EEEA in our department between 2010-2018 were retrospectively analyzed. The lesions were located in the midline between the posterior wall of the frontal sinus and tuberculum sella. Tumor locations, histopathological diagnoses, surgical techniques, outcomes and complications were documented. RESULTS Eleven patients were female and 13 were male. Their ages ranged between 18-75 years (mean 40.5 years). Considering their locations; 12 were in the anterior fossa (50 %), 7 were in the tuberculum sella (29.1 %), and 5 were in both anatomic sites (20.8 %). Histopathologically, our series consisted of 15 meningiomas, 6 osteomas, 2 dermoid tumors and 1 metastatic carcinoma. We achieved gross total resection in 75 % of our patients. Ten patients presented with visual complaints and 7 of them improved postoperatively. Postoperative cerebrospinal fluid leakage (CSF) was observed in 3 patients and one of them developed meningitis and subsequently died of sepsis. CONCLUSION Although the number of cases is low, EEEA seems like a safe, effective and well-tolerated treatment modality for anterior midline skull base lesions. But strict preventive measures should be taken for a possible CSF leak.
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Affiliation(s)
- Mehmet İlker Özer
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Ahmet Murat Kutlay
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Mehmet Ozan Durmaz
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Alparslan Kirik
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Soner Yaşar
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Özkan Tehli
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Cahit Kural
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Nail Çağlar Temiz
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Abdullah Durmaz
- Department of Otorhinolaryngology, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Mehmet Can Ezgu
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Mehmet Kadri Daneyemez
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey
| | - Yusuf Izci
- Department of Neurosurgery, University of Health Sciences, Gulhane School of Medicine, Ankara, Turkey.
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13
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Vaz-Guimaraes F, Fernandez-Miranda JC, Koutourousiou M, Hamilton RL, Wang EW, Snyderman CH, Gardner PA. Endoscopic Endonasal Surgery for Cranial Base Chondrosarcomas. Oper Neurosurg (Hagerstown) 2019; 13:421-434. [PMID: 28838112 DOI: 10.1093/ons/opx020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/24/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Microsurgical resection via open approaches is considered the main treatment modality for cranial base chondrosarcomas (CBCs). The use of endoscopic endonasal approaches (EEAs) has been rarely reported. OBJECTIVE To present the endoscopic endonasal experience with CBCs at our institution. METHODS Retrospective review of the medical records of 35 consecutive patients who underwent EEA for CBC resection between January 2004 and April 2013. Surgical outcomes and variables that might affect extent of resection, complications, and recurrence were analyzed. RESULTS Forty-eight operations were performed (42 EEAs and 6 open approaches). Gross-total resection was achieved in 22 patients (62.9%), near total (≥90% tumor resection) in 11 (31.4%). Larger tumors were associated with incomplete resection in univariate and multivariate analysis ( P = .004, .015, respectively). In univariate analysis, tumors involving the lower clivus and cerebellopontine angle were associated with increased number of complications, especially postoperative cerebrospinal fluid leak ( P = .015) and new cranial neuropathy ( P = .037), respectively. Other major complications included 2 cases of meningitis and deep venous thrombosis, and 1 case of hydrocephalus and carotid injury. Involvement of the lower clivus, parapharyngeal space, and cervical spine required a combination of approaches to maximize tumor resection ( P = .017, .044, .017, respectively). No predictors were significantly associated with increased risk of recurrence. The average follow-up time was 44.6 ± 31 months. CONCLUSIONS EEAs may be considered a good option for managing CBCs without significant posterolateral extension beyond the basal foramina and can be used in conjunction with open approaches for maximal resection with acceptable morbidity.
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Affiliation(s)
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Maria Koutourousiou
- Department of Neurolog-ical Surgery, University of Louisville, Louisville, Kentucky
| | | | - Eric W Wang
- Department of Oto-laryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Carl H Snyderman
- Department of Oto-laryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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14
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The Evolution of Endoscopic Skull Base Surgery Outcomes: Defining the Edge of the Envelope. World Neurosurg 2019. [DOI: 10.1016/j.wneu.2019.01.119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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15
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Schwartz TH, Morgenstern PF, Anand VK. Lessons learned in the evolution of endoscopic skull base surgery. J Neurosurg 2019; 130:337-346. [PMID: 30717035 DOI: 10.3171/2018.10.jns182154] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/01/2018] [Indexed: 01/29/2023]
Abstract
OBJECTIVEEndoscopic skull base surgery (ESBS) is a relatively recent addition to the neurosurgical armamentarium. As with many new approaches, there has been significant controversy regarding its value compared with more traditional approaches to ventral skull base pathology. Although early enthusiasm for new approaches that appear less invasive is usually high, these new techniques require rigorous study to ensure that widespread implementation is in the best interest of patients.METHODSThe authors compared surgical results for ESBS with transcranial surgery (TCS) for several different pathologies over two different time periods (prior to 2012 and 2012-2017) to see how results have evolved over time. Pathologies examined were craniopharyngioma, anterior skull base meningioma, esthesioneuroblastoma, chordoma, and chondrosarcoma.RESULTSESBS offers clear advantages over TCS for most craniopharyngiomas and chordomas. For well-selected cases of planum sphenoidale and tuberculum sellae meningiomas, ESBS has similar rates of resection with higher rates of visual improvement, and more recent results with lower CSF leaks make the complication rates similar between the two approaches. TCS offers a higher rate of resection with fewer complications for olfactory groove meningiomas. ESBS is preferred for lower-grade esthesioneuroblastomas, but higher-grade tumors often still require a craniofacial approach. There are few data on chondrosarcomas, but early results show that ESBS appears to offer clear advantages for minimizing morbidity with similar rates of resection, as long as surgeons are familiar with more complex inferolateral approaches.CONCLUSIONSESBS is maturing into a well-established approach that is clearly in the patients' best interest when applied by experienced surgeons for appropriate pathology. Ongoing critical reevaluation of outcomes is essential for ensuring optimal results.
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Affiliation(s)
- Theodore H Schwartz
- Departments of1Neurological Surgery and
- 2Otorhinolaryngology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York; and
- 3Department of Neuroscience, Weill Cornell Medical College, New York, New York
| | | | - Vijay K Anand
- 2Otorhinolaryngology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, New York; and
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16
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Banaz F, Edem I, Moldovan ID, Kilty S, Jansen G, Alkherayf F. Chondrosarcoma in the Petrous Apex: Case Report and Review. J Neurol Surg Rep 2018; 79:e83-e87. [PMID: 30473986 PMCID: PMC6193802 DOI: 10.1055/s-0038-1673627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 08/28/2018] [Indexed: 11/12/2022] Open
Abstract
Introduction Surgical treatment of petrous apex chondrosarcoma is challenging due to the location of the tumor. Using an endoscopic technique for tumor resection is favored since it provides a minimally invasive approach. Case Presentation A 57 years old female was admitted for acute onset of left abducens nerve palsy and occasional headache mainly on the left side of the retro-orbital area with some radiation to the left occiput. Magnetic resonance imaging (MRI) and computed tomography (CT), at the time of admission, were showed lytic lesion on the left petrous apex and left part of the clivus. Results of metastatic workup were negative. The surgical procedure considered was expanded endoscopic endonasal transclival approach to the left of the petrous apex and reconstruction with a pedicled nasoseptal flap with image guidance system. The pathology confirmed chondrosarcoma on myxoid background. The surgical procedure was uncomplicated. The abducens nerve palsy was resolved in few weeks and no new deficits occurred. Postoperative MRI showed complete resection of the tumor. Conclusion Expanded endoscopic endonasal transclival approach to petrous apex and reconstruction appears to be safe and feasible technique, capable of achieving total removal of identified lesions near the petrous apex. Nonetheless, future studies with a greater number of patients are crucial to confirm and consolidate this initial impression.
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Affiliation(s)
- F. Banaz
- Department of Otolaryngology- Head & Neck Surgery, The Ottawa Hospital, Ottawa, Canada
| | - I. Edem
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, Canada
| | - I. D. Moldovan
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
| | - S. Kilty
- Department of Otolaryngology- Head & Neck Surgery, The Ottawa Hospital, Ottawa, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
| | - G. Jansen
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital, Ottawa, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, Canada
| | - F. Alkherayf
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Canada
- University of Ottawa, Faculty of Medicine, Ottawa, Canada
- The Ottawa Hospital Research Institute, Ottawa, Canada
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17
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van Koevering K, Prevedello DM, Carrau RL. Endoscopic endonasal approaches for the management of cranial base malignancies: histologically guided treatment and clinical outcomes. J Neurosurg Sci 2018; 62:667-681. [PMID: 29808637 DOI: 10.23736/s0390-5616.18.04507-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Malignancies of the skull base represent a highly diverse and challenging set of pathologies which exhibit a wide array of oncologic behavior. In recent decades, a number of important advances in treatment technique have evolved to improve oncologic outcomes and reduce morbidity in the treatment of these aggressive cancers. Intensity modulated radiation therapy has become the gold standard in radiotherapy owing to its precision planning and reduced morbidity. However heavy ion particle radiation (proton therapy, carbon ion, etc.) are recently emerging with promising results at the skull base related to the reduced exit dose to adjacent structures. Novel systemic therapeutics such as targeted and immunotherapies may dramatically alter the treatment paradigm for many of these pathologies. Nevertheless, most skull base malignancies remain surgical diseases. The evolution of the expanded endonasal approach for a minimally invasive surgical resection has proven validity in treating many of these pathologies when properly selected, and have largely supplanted open approaches owing to the reduced morbidity profile. In spite of these important advances, the most critical aspect in comprehensive treatment is a detailed understanding of the oncologic behavior and outcomes data for each of the specific histopathologies encountered at the skull base. The nuances in management strategy, histologic profile, and surveillance planning can be stratified through the development of a comprehensive, multidisciplinary skull base team to maximize therapeutic effect and minimize morbidity for each patient. This review aims to summarize the key body of data and approaches for each of the histologies frequently encountered in the skull base, while highlighting the value and technique of endonasal approaches.
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Affiliation(s)
- Kyle van Koevering
- Department of Otolaryngology, Head and Neck Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Daniel M Prevedello
- Department of Neurosurgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Ricardo L Carrau
- Department of Neurosurgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA -
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18
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Aref MH, Youssef AS. Training the skull base surgeon of the future: a comprehensive approach. J Neurosurg Sci 2018; 62:627-635. [PMID: 29790723 DOI: 10.23736/s0390-5616.18.04475-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The tremendous advances in endoscopic skull base surgery added a new set of intricate less invasive approaches to the neurosurgical armamentarium. The new generations of neurosurgeons face the challenge of adopting the ever-changing technology and quickly learning modern surgical techniques beyond the traditional neurosurgery comfort zone. The future skull base surgeon must be well trained and knowledgeable in all surgical portals to the skull base in order to select the safest, least invasive, most direct approach that offers the optimum exposure to handle a complex skull base pathology. The multi-portal/corridor philosophy is often adopted in order to achieve superior surgical and clinical outcomes. Neurosurgeons need to consider such an approach when appropriate as it may offer a superior outcome while minimizing the morbidity associated with large exposures.
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Affiliation(s)
- Mohammed H Aref
- Department of Neurosurgery, University of Colorado, Aurora, CO, USA.,King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - A Samy Youssef
- Department of Neurosurgery, University of Colorado, Aurora, CO, USA -
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19
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Kutlay M, Durmaz A, Özer İ, Kural C, Temiz Ç, Kaya S, Solmaz İ, Daneyemez M, Izci Y. Extended endoscopic endonasal approach to the ventral skull base lesions. Clin Neurol Neurosurg 2018; 167:129-140. [DOI: 10.1016/j.clineuro.2018.02.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 02/13/2018] [Accepted: 02/19/2018] [Indexed: 02/08/2023]
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20
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Doglietto F, Ferrari M, Mattavelli D, Belotti F, Rampinelli V, Kheshaifati H, Lancini D, Schreiber A, Sorrentino T, Ravanelli M, Buffoli B, Hirtler L, Maroldi R, Nicolai P, Rodella LF, Fontanella MM. Transnasal Endoscopic and Lateral Approaches to the Clivus: A Quantitative Anatomic Study. World Neurosurg 2018; 113:e659-e671. [PMID: 29499424 DOI: 10.1016/j.wneu.2018.02.118] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 02/18/2018] [Accepted: 02/19/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Transnasal endoscopic approaches to the clivus have been established recently. Comparative analyses with classic lateral approaches are limited. In this study, we compared transnasal endoscopic and lateral approaches to the clivus, quantifying the exposure and working volume of each approach in the anatomy laboratory. METHODS High-resolution computed tomography scans were performed on 5 injected specimens (10 sides). In each specimen, transnasal endoscopic approaches (i.e., paraseptal, transrostral, extended transrostral, transethmoidal, and extended transclival without and with intradural hypophysiopexy) and lateral approaches (i.e., retrosigmoid, far-lateral, presigmoid retrolabyrinthine and translabyrinthine) to the clivus were performed. An optic neuronavigation system and dedicated software (ApproachViewer; Guided Therapeutics Program, University Health Network, Toronto, Ontario, Canada) were used to quantify the working volume and exposed clival area of each approach. Statistical evaluation was performed with the Kruskal-Wallis test and Steel-Dwass-Critchlow-Fligner post hoc test. RESULTS Endoscopic transnasal transclival approaches showed higher working volume and larger clival exposure compared with lateral approaches. Incremental volumetric values were evident for transnasal approaches; presigmoid approaches provided less working volume than retrosigmoid approaches. A transnasal transclival approach with hypophysiopexy provided significant exposure of the upper clivus (84.4%). The transrostral approach was the first transnasal approach providing satisfactory access to the midclivus (66%); retrosigmoid and far-lateral approaches provided exposure of approximately one half of the midclivus. The lower clivus was optimally exposed with endoscopic transclival approaches (83%), whereas access to this region was limited with lateral approaches. CONCLUSIONS This quantitative anatomic study shows that endoscopic transnasal approaches to the clivus provide a larger working volume and wider exposure of the clivus compared with lateral approaches.
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Affiliation(s)
- Francesco Doglietto
- Department of Neurosurgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
| | - Marco Ferrari
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Davide Mattavelli
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Francesco Belotti
- Department of Neurosurgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Vittorio Rampinelli
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Hussein Kheshaifati
- Department of Neurosurgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy; Department of Neurosurgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Davide Lancini
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Alberto Schreiber
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Tommaso Sorrentino
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Ravanelli
- Department of Radiology, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Barbara Buffoli
- Department of Anatomy and Physiopathology, Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Lena Hirtler
- Department of Systematic Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Roberto Maroldi
- Department of Radiology, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Piero Nicolai
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Fabrizio Rodella
- Department of Anatomy and Physiopathology, Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marco Maria Fontanella
- Department of Neurosurgery, Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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21
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Zheng JP, Li CZ, Chen GQ, Song GD, Zhang YZ. Three-Dimensional Printed Skull Base Simulation for Transnasal Endoscopic Surgical Training. World Neurosurg 2018; 111:e773-e782. [PMID: 29309974 DOI: 10.1016/j.wneu.2017.12.169] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 12/23/2017] [Accepted: 12/27/2017] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Transnasal endoscopic skull base surgery (SBS) presents a major challenge for inexperienced neurosurgeons because of the complicated anatomic structures, 2-dimensional endoscopic view, limited operative field, and required skills. We designed a personalized multimaterial and multicolor three-dimensional (3D)-printed SBS simulation to reproduce the complex anatomy of the skull base. The fidelity and feasibility for anatomic education and surgical training were assessed. METHODS Two-dimensional computer tomography and magnetic resonance images were collected from a 42-year-old healthy male volunteer. After 3D modeling and spatial alignment, personalized SBS simulations were produced using a multimaterial 3D printer. The fidelity of the models was assessed by 3 experienced neurosurgeons, and the effects for anatomic education and surgical training were evaluated by 10 resident trainees. Both evaluations were based on 5-point Likert questionnaires. RESULTS The mean scores for fidelity of tissue structure ranged from 3.7 to 4.7, and scores for aid in anatomic education and surgical training ranged from 3.5 to 4.9. CONCLUSION The 3D-printed SBS simulation is a practical, economical, high-fidelity model. It has great potential for anatomic education and operative training in transnasal endoscopic surgery.
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Affiliation(s)
- Jia-Ping Zheng
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chu-Zhong Li
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guo-Qiang Chen
- Department of Neurosurgery Center, Aviation General Hospital of China Medical University, Beijing, China
| | - Gui-Dong Song
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ya-Zhuo Zhang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Beijing Institute for Brain Disorders Brain Tumor Center, China National Clinical Research Center for Neurological Diseases, Key Laboratory of Central Nervous System Injury Research, Capital Medical University, Beijing, China.
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Proposed Treatment Paradigm for Intracranial Chondrosarcomas Based on Multidisciplinary Coordination. World Neurosurg 2017; 109:e517-e530. [PMID: 29033377 DOI: 10.1016/j.wneu.2017.10.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 10/02/2017] [Accepted: 10/04/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVES There was no consensus regarding the treatment of intracranial chondrosarcoma (CSA). The study aimed to evaluate the adverse factors for progression-free survival (PFS) and overall survival (OS) and to propose a treatment strategy for CSA. METHODS The clinical chart and radiographic data of 106 consecutive cases (mesenchymal and conventional CSA in 18 and 88 patients, respectively) of surgically treated CSAs were retrospectively reviewed. RESULTS Gross total resection was achieved in 43 patients (40.6%), and adjuvant radiotherapy was administered in 45 patients. After a mean follow-up duration of 47.8 months, 38 patients (37.3%) experienced recurrence. PFS and disease-specific OS at 5 years was 57.7% and 74.4%. Independent adverse factors for PFS were previous surgery (hazard ratio [HR] 2.261; P = 0.028), increased lesion size (HR, 1.298; P = 0.026), extent of surgical resection (HR, 3.226; P < 0.001), malignant pathology (HR, 2.018; P = 0.003), and postoperative radiotherapy (HR, 3.246; P = 0.001). The stereotactic radiosurgery subgroup presented best 5-year PFS of 88.9%, and a linear accelerator prolonged the mean PFS time (57.0 months) compared with no radiation (38.1 months). In the incomplete resection subgroup (n = 63), radiotherapy significantly benefited tumor control (HR, 2.101; P = 0.016). Extent of surgical resection (HR, 1.797; P = 0.026) and malignant disease (HR, 1.717; P = 0.030) were associated with OS. CONCLUSIONS Intracranial CSAs were not completely amendable by surgery alone. Gross total resection as far as possible plus radiation were necessary for mesenchymal CSA and conventional CSA with active growth or residual tumor. Stereotactic radiosurgery was an alternative if proton therapy was unavailable. A future study with a large cohort is required to verify our findings.
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Folbe AJ, Svider PF, Liu JK, Eloy JA. Endoscopic Resection of Clival Malignancies. Otolaryngol Clin North Am 2017; 50:315-329. [PMID: 28314400 DOI: 10.1016/j.otc.2016.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Surgical management of clival lesions presents numerous therapeutic challenges because of the close proximity of surrounding critical structures. With a detailed understanding of the endoscopic endonasal approach and relevant considerations, appropriate lesions can be removed in a safe and minimally invasive manner. Use of this technique as a primary approach represents the standard of care for many lesions at leading skull base centers, although adjunct techniques may be necessary in extensive lesions and those with significant lateral extension.
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Affiliation(s)
- Adam J Folbe
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, 4201 St. Antoine, 5E-UHC, Detroit, MI 48201, USA; Department of Neurosurgery, Wayne State University School of Medicine, 4201 St. Antoine, 5E-UHC, Detroit, MI 48201, USA
| | - Peter F Svider
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, 4201 St. Antoine, 5E-UHC, Detroit, MI 48201, USA.
| | - James K Liu
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ 07103, USA; Department of Neurological Surgery, Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ 07103, USA
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ 07103, USA; Department of Neurological Surgery, Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ 07103, USA; Endoscopic Skull Base Surgery Program, Rhinology and Sinus Surgery, Otolaryngology Research, Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ 07103, USA; Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ 07103, USA
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The Unusual Presentation of a Myxoma Within the Sphenoid Sinus: Case Report and Review of the Literature. World Neurosurg 2017; 103:951.e5-951.e12. [PMID: 28433840 DOI: 10.1016/j.wneu.2017.04.019] [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: 10/18/2016] [Revised: 04/02/2017] [Accepted: 04/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND We describe a rare case of a sphenoid sinus myxoma that was resected via an endoscopic endonasal skull base approach. We review the literature regarding these rare tumors of the paranasal sinuses. CASE DESCRIPTION A 72-year-old woman was diagnosed with an incidental sphenoid sinus tumor and left sphenoid wing meningioma during a workup for left-sided proptosis and diplopia. Biopsies of the sphenoid wing and sphenoid sinus tumors were obtained. After undergoing surgical resection of the meningioma, the patient then underwent definitive resection of the sphenoid sinus myxoma via endoscopic endonasal skull base approach. Postoperative imaging demonstrated a gross total resection. The patient suffered postoperative thromboembolic complications due to underlying hypercoagulable state but made a complete recovery and returned to her neurologic baseline. There has been no evidence of recurrent myxoma in the sphenoid sinus 24 months after surgery. DISCUSSION Myxomas are benign tumors derived from primitive mesenchyme. Myxomas very rarely present in the paranasal or skull base location. Complete surgical resection is the primary treatment for these tumors. The endoscopic endonasal approach is an effective technique for resecting various benign and more aggressive extradural skull base tumors. CONCLUSIONS Myxomas of the sphenoid sinus are rare. The endoscopic endonasal skull base approach is an effective and minimal access technique for resection of this rare tumor of the sphenoid sinus.
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Mason E, Rompaey JV, Solares CA, Figueroa R, Prevedello D. Subtemporal Retrolabyrinthine (Posterior Petrosal) versus Endoscopic Endonasal Approach to the Petroclival Region: An Anatomical and Computed Tomography Study. J Neurol Surg B Skull Base 2016; 77:231-7. [PMID: 27175318 DOI: 10.1055/s-0035-1566123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 09/03/2015] [Indexed: 10/22/2022] Open
Abstract
Background The petroclival region seats many neoplasms. Traditional surgical corridors to the region can result in unacceptable patient morbidity. The combined subtemporal retrolabyrinthine transpetrosal (posterior petrosal) approach provides adequate exposure with hearing preservation; however, the facial nerve and labyrinth are put at risk. Approaching the petroclival region with an endoscopic endonasal approach (EEA) could minimize morbidity. Objective To provide an anatomical and computed tomography (CT) comparison between the posterior petrosal approach and EEA to the petroclival region. Methods The petroclival region was approached transclivally with EEA. Different aspects of dissection were compared with the posterior petrosal approach. The two approaches were also studied using CT analysis. Results A successful corridor medial to the internal auditory canal (IAC) was achieved with EEA. Wide exposure was achieved with no external skin incisions, although significant sinonasal resection was required. The posterior petrosal was comparable in terms of exposure medially; however, the dissection involved more bone removal, greater skill, and a constricting effect upon deeper dissection. Importantly, access lateral to the IAC was obtained, whereas EEA could not reach this area. Conclusion An EEA to the petroclival region is feasible. This approach can be considered in lesions medial to the IAC.
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Affiliation(s)
- Eric Mason
- Department of Otolaryngology, Georgia Regents University, Augusta, Georgia, United States; Center for Cranial Base Surgery, Georgia Regents University, Augusta, Georgia, United States
| | - Jason Van Rompaey
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, United States
| | - C Arturo Solares
- Department of Otolaryngology, Georgia Regents University, Augusta, Georgia, United States; Center for Cranial Base Surgery, Georgia Regents University, Augusta, Georgia, United States
| | - Ramon Figueroa
- Department of Radiology, Georgia Regents University, Augusta, Georgia, United States
| | - Daniel Prevedello
- Department of Neurosurgery, Ohio State University, Columbus, Ohio, United States
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