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Agosti E, De Maria L, Mattogno PP, Della Pepa GM, D’Onofrio GF, Fiorindi A, Lauretti L, Olivi A, Fontanella MM, Doglietto F. Quantitative Anatomical Studies in Neurosurgery: A Systematic and Critical Review of Research Methods. Life (Basel) 2023; 13:1822. [PMID: 37763226 PMCID: PMC10532642 DOI: 10.3390/life13091822] [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: 07/10/2023] [Revised: 08/17/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The anatomy laboratory can provide the ideal setting for the preclinical phase of neurosurgical research. Our purpose is to comprehensively and critically review the preclinical anatomical quantification methods used in cranial neurosurgery. METHODS A systematic review was conducted following the PRISMA guidelines. The PubMed, Ovid MEDLINE, and Ovid EMBASE databases were searched, yielding 1667 papers. A statistical analysis was performed using R. RESULTS The included studies were published from 1996 to 2023. The risk of bias assessment indicated high-quality studies. Target exposure was the most studied feature (81.7%), mainly with area quantification (64.9%). The surgical corridor was quantified in 60.9% of studies, more commonly with the quantification of the angle of view (60%). Neuronavigation-based methods benefit from quantifying the surgical pyramid features that define a cranial neurosurgical approach and allowing post-dissection data analyses. Direct measurements might diminish the error that is inherent to navigation methods and are useful to collect a small amount of data. CONCLUSION Quantifying neurosurgical approaches in the anatomy laboratory provides an objective assessment of the surgical corridor and target exposure. There is currently limited comparability among quantitative neurosurgical anatomy studies; sharing common research methods will provide comparable data that might also be investigated with artificial intelligence methods.
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Affiliation(s)
- Edoardo Agosti
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
| | - Lucio De Maria
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
- Division of Neurosurgery, Department of Clinical Neuroscience, Geneva University Hospitals (HUG), 1205 Geneva, Switzerland
| | - Pier Paolo Mattogno
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
| | - Giuseppe Maria Della Pepa
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
| | | | - Alessandro Fiorindi
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
| | - Liverana Lauretti
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
| | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
| | - Francesco Doglietto
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
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Tayebi Meybodi A, Benet A, Rodriguez Rubio R, Yousef S, Lawton MT. Analysis of Surgical Freedom Variation Across the Basilar Artery Bifurcation: Towards a Deeper Insight Into Approach Selection for Basilar Apex Aneurysms. Oper Neurosurg (Hagerstown) 2018. [PMID: 29514321 DOI: 10.1093/ons/opy012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The orbitozygomatic approach is generally advocated over the pterional approach for basilar apex aneurysms. However, the impact of the extensions of the pterional approach on the obtained maneuverability over multiple vascular targets (relevant to basilar apex surgery) has not been studied before. OBJECTIVE To analyze the patterns of surgical freedom change across the basilar bifurcation between the pterional, orbitopterional, and orbitozygomatic approaches. METHODS Surgical freedom was assessed for 3 vascular targets important in basilar apex aneurysm surgery (ipsilateral and contralateral P1-P2 junctions, and basilar apex), and compared between the pterional, orbitopterional, and orbitozygomatic approaches in 10 cadaveric specimens. RESULTS Transitioning from the pterional to orbitopterional approach, the surgical freedom increased significantly at all 3 targets (P < .05). However, the gain in surgical freedom declined progressively from the most superficial target (60% for ipsilateral P1-P2 junction) to the deepest target (35% for contralateral P1-P2 junction). Conversely, transitioning from the orbitopterional to the orbitozygomatic approach, the gain in surgical freedom was minimal for the ipsilateral P1-P2 and basilar apex (<4%), but increased dramatically to 19% at the contralateral P1-P2 junction. CONCLUSION The orbitopterional approach provides a remarkable increase in surgical maneuverability compared to the pterional approach for the basilar apex target and the relevant adjacent arterial targets. However, compared to the orbitopterional, the orbitozygomatic approach adds little maneuverability except for the deepest target (ie, contralateral P1-P2 junction). Therefore, the orbitozygomatic approach may be most efficacious with larger basilar apex aneurysms limiting the control over of the contralateral P1 PCA.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Arnau Benet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Sonia Yousef
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
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Tayebi Meybodi A, Benet A, Rodriguez Rubio R, Yousef S, Lawton MT. Comprehensive Anatomic Assessment of the Pterional, Orbitopterional, and Orbitozygomatic Approaches for Basilar Apex Aneurysm Clipping. Oper Neurosurg (Hagerstown) 2018; 15:538-550. [PMID: 29281073 DOI: 10.1093/ons/opx265] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 11/07/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The pterional approach, along with its orbitopterional and orbitozygomatic extensions, is among the most common surgical approaches for tackling challenging aneurysms of the basilar artery apex (BAX). There is general consensus that the orbitozygomatic approach provides the best exposure for these lesions. However, there is little objective evidence to support approach selection for surgical treatment of BAX aneurysms. OBJECTIVE To compare different features regarding surgical treatment of BAX aneurysms between the pterional, orbitopterional, and orbitozygomatic approaches. METHODS The pterional, orbitopterional, and orbitozygomatic approaches were sequentially completed on 10 cadaveric specimens. The visibility of perforators, lengths of exposure, and safe clipping for major BAX branches, surgical area of exposure, and the surgical freedom for the BAX target were assessed. RESULTS The orbitopterional approach provided significantly greater values than the pterional approach in all variables, except for exposure of the bilateral P1 posterior cerebral artery (PCA) perforators. When compared to the orbitopterional approach, the orbitozygomatic approach did not provide a statistically significant increase in (1) surgical freedom through the carotid-oculomotor triangle, (2) area of exposure, (3) ipsilateral, and (4) contralateral P1 PCA perforator visibility, and (5) ipsilateral PCA exposure and (6) clipping lengths. CONCLUSION The orbitopterional approach provides significantly greater surgical exposure to BAX than the pterional approach. The orbitopterional approach is less invasive while providing similar surgical access to the BAX compared to the orbitozygomatic. The results of this study show that the orbitopterional approach may be optimal for the treatment of most BAX aneurysms, particularly to reduce morbidity resulting from the full orbitozygomatic approach.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Arnau Benet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Roberto Rodriguez Rubio
- Department of Neurosurgery, Skull Base and Cerebrovascular Laboratory, University of California, San Francisco
| | - Sonia Yousef
- Department of Neurosurgery, Skull Base and Cerebrovascular Laboratory, University of California, San Francisco
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
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Tayebi Meybodi A, Benet A, Rodriguez Rubio R, Yousef S, Mokhtari P, Preul MC, Lawton MT. Comparative Analysis of Orbitozygomatic and Subtemporal Approaches to the Basilar Apex: A Cadaveric Study. World Neurosurg 2018; 119:e607-e616. [PMID: 30077027 DOI: 10.1016/j.wneu.2018.07.217] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/23/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The subtemporal and orbitozygomatic approaches are the most commonly used surgical approaches for the treatment of basilar artery apex (BAX) aneurysms. Relative advantages and disadvantages are generally reported based on surgeons' experience. This study was performed to provide a detailed comparison between the subtemporal and orbitozygomatic approaches based on cadaveric dissection analysis for the treatment of BAX aneurysms. METHODS Subtemporal and orbitozygomatic approaches were performed on 5 cadaveric heads (10 sides), and the following variables were assessed and compared between the 2 approaches: 1) number of exposed perforators on P1-posterior cerebral arteries (PCA); 2) lengths of exposure and clipping for bilateral PCA, superior cerebellar arteries (SCA), and basilar trunk; 3) surgical area of exposure; and 4) surgical freedom at the BAX. RESULTS Number of perforators exposed on P1-PCA was not different between the subtemporal and orbitozygomatic approaches. Exposure and clipping of ipsilateral SCA and PCA were superior using the subtemporal approach, and better for contralateral SCA and PCA using the orbitozygomatic approach, all reaching statistical significance. The orbitozygomatic approach provided greater exposure and clipping length for the proximal basilar trunk. Although the surgical area of exposure was similar between the 2 approaches, the overall surgical freedom was greater in the orbitozygomatic approach. CONCLUSIONS The orbitozygomatic approach provides a greater number of surgical corridors to the BAX and is superior regarding multiple surgically relevant anatomic parameters. Importantly, control over the basilar trunk and over the contralateral SCA and PCA (blind spots) is superior with the orbitozygomatic approach.
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Affiliation(s)
- Ali Tayebi Meybodi
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Arnau Benet
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Sonia Yousef
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, USA
| | - Pooneh Mokhtari
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Mark C Preul
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Michael T Lawton
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA.
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The Tentorial Bridge to Deep Skull Base Exposure: Anatomic Morphometric Study. World Neurosurg 2018; 114:e588-e596. [PMID: 29551719 DOI: 10.1016/j.wneu.2018.03.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/02/2018] [Accepted: 03/05/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Skull base surgeons split the tentorium to expand exposure, minimize brain retraction, and combine the supratentorial and infratentorial compartments for resection of large skull base lesions. The aim of this study was to describe stepwise techniques for splitting the tentorium to access deeply located skull base lesions and morphometrically assess gained exposure. METHODS Surgical exposures were performed through transsylvian, subtemporal, posterior transpetrosal, and combined posterior supratentorial/infratentorial-transsinus approaches. A custom software program was used to trace the surgical exposure region of interest for area analysis with the ability to accurately assess most irregular areas. Qualitative morphometric assessment was done of the gain in anatomic exposure achieved by splitting the tentorium. RESULTS In the transsylvian transtentorial approach, mean surface area increased 154.17%, from 0.14 cm2 before expansion to 0.32 cm2 after expansion. In the subtemporal transtentorial approach, mean surface area increased 137.61%, from 0.66 cm2 before expansion to 1.52 cm2 after expansion. In the posterior transpetrosal transtentorial approach, mean surface area increased 171.06%, from 1.08 cm2 before expansion to 2.81 cm2 after expansion. In the combined supratentorial/infratentorial-transsinus approach, mean surface area increased 222.03%, from 0.78 cm2 before expansion to 2.38 cm2 after expansion. CONCLUSIONS With splitting of the tentorium, a substantial area of expansion is obtained, minimizing the need for brain retraction and improving visualization of deep neurovascular structures in the skull base.
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Sellin JN, Srinivasan VM, Navarro JC, Batjer HH, Van Loveren H, Duckworth EA. Transcavernous Approach to the Basilar Apex: A Cadaveric Prosection. Cureus 2018; 10:e2192. [PMID: 29682431 PMCID: PMC5908389 DOI: 10.7759/cureus.2192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The transcavernous approach to the basilar artery, as initially described by Dolenc, is one of the most common and elegant approaches to the region. It affords a generous working and viewing angle, but it can be technically challenging and requires attention to detail at each step. We investigate this approach in this report via a cadaveric prosection with a focus on the value of each of the component steps in improving surgical view and exposure. The transcavernous approach steps are divided into extradural stages: orbitozygomatic osteotomy (a modern adjunct to Dolenc's original description), drilling of the lesser sphenoid wing, and anterior clinoidectomy; and intradural stages: wide splitting of the Sylvian fissure, unroofing of the oculomotor and trochlear nerves, and posterior clinoidectomy. The surgical windows afforded by each step in the approach are illustrated using microscopic images taken during the cadaveric prosection of a donor who happened to harbor a basilar apex aneurysm. An illustrative case and artist illustrations are used to emphasize the relative value of each step of the transcavernous exposure.
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Affiliation(s)
| | | | - Jovany C Navarro
- Department of Anesthesiology, Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Hunt H Batjer
- Department of Neurosurgery, UT Southwestern Medical Center, Dallas, TX
| | - Harry Van Loveren
- Department of Neurosurgery, University of South Florida Morsani College of Medicine
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Nakov VS, Spiriev TY, Todorov IT, Simeonov P. Technical nuances of subtemporal approach for the treatment of basilar tip aneurysm. Surg Neurol Int 2017; 8:15. [PMID: 28217394 PMCID: PMC5309464 DOI: 10.4103/2152-7806.199555] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 11/10/2016] [Indexed: 11/17/2022] Open
Abstract
Background: Basilar tip aneurysms are one of the most complex vascular lesions to treat surgically because of their location, depth of the approach, and close proximity of vital neurovascular structures such as the mesencephalon, cranial nerves, perforating arteries to the thalamus. There are different surgical approaches utilized to reach basilar tip aneurysms, namely, pterional, pretemporal, orbitozygomatic, subtemporal, and anterior petrosectomy. Each of them has its advantages and limitations. Methods: In this paper, we present our personal experience with the use of subtemporal approach. The technique is described in detail including its nuances and potential pitfalls. Results: The subtemporal approach is indicated for basilar tip aneurysms located at the level of the floor of the sella turcica to 1 cm above the dorsum sellae. Conclusion: Subtemporal approach offers good surgical corridor for the management of these complex vascular lesions.
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Affiliation(s)
| | - Toma Y Spiriev
- Department of Neurosurgery, Tokuda Hospital, Sofia, Bulgaria
| | - Ivan T Todorov
- Department of Neurosurgery, Military Medical Academy, Sofia, Bulgaria
| | - Plamen Simeonov
- Department of Neurosurgery, Military Medical Academy, Sofia, Bulgaria
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Spiriev T, Ebner FH, Hirt B, Shiozawa T, Gleiser C, Tatagiba M, Herlan S. Fronto-temporal branch of facial nerve within the interfascial fat pad: is the interfascial dissection really safe? Acta Neurochir (Wien) 2016; 158:527-32. [PMID: 26801513 DOI: 10.1007/s00701-016-2711-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 01/11/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND The study was conducted to clarify the presence or absence of fronto-temporal branches (FTB) of the facial nerve within the interfascial (between the superficial and deep leaflet of the temporalis fascia) fat pad. METHODS Eight formalin-fixed cadaveric heads (16 sides) were used in the study. The course of the facial nerve and the FTB was dissected in its individual tissue planes and followed from the stylomastoid foramen to the frontal region. RESULTS In the fronto-temporal region, above the zygomatic arch, FTB gives several small twigs running anteriorly in the fat pad above the superficial temporalis fascia and a branch within the temporo-parietal fascia (TPF) to the muscles of the forehead. There were no twigs of the FTB within the interfascial fat pad. CONCLUSIONS No branches of the FTB are found in the interfascial (between the superficial and deep leaflet of the temporalis fascia) fat pad. The interfascial dissection can be safely performed without risk of injury to the FTB and potential subsequent frontalis palsy.
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Affiliation(s)
- Toma Spiriev
- Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Hoppe-Seyler-Str.3, 72076, Tübingen, Germany.
| | - Florian Heinrich Ebner
- Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Hoppe-Seyler-Str.3, 72076, Tübingen, Germany
| | - Bernhard Hirt
- Institute of Clinical Anatomy and Cell Analysis, Eberhard-Karls-University, Elfriede-Aulhorn-Str.8, 72076, Tübingen, Germany
| | - Thomas Shiozawa
- Institute of Clinical Anatomy and Cell Analysis, Eberhard-Karls-University, Elfriede-Aulhorn-Str.8, 72076, Tübingen, Germany
| | - Corinna Gleiser
- Institute of Clinical Anatomy and Cell Analysis, Eberhard-Karls-University, Elfriede-Aulhorn-Str.8, 72076, Tübingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Hoppe-Seyler-Str.3, 72076, Tübingen, Germany
| | - Stephan Herlan
- Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Hoppe-Seyler-Str.3, 72076, Tübingen, Germany
- Institute of Clinical Anatomy and Cell Analysis, Eberhard-Karls-University, Elfriede-Aulhorn-Str.8, 72076, Tübingen, Germany
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Quantification and comparison of neurosurgical approaches in the preclinical setting: literature review. Neurosurg Rev 2016; 39:357-68. [PMID: 26782812 DOI: 10.1007/s10143-015-0694-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 03/25/2015] [Accepted: 06/27/2015] [Indexed: 12/14/2022]
Abstract
There is a growing awareness of the need for evidence-based surgery and of the issues that are specific to research in surgery. Well-conducted anatomical studies can represent the first, preclinical step for evidence-based surgical innovation and evaluation. In the last two decades, various reports have quantified and compared neurosurgical approaches in the anatomy laboratory using different methods and technology. The aim of this study was to critically review these papers. A PubMed and Scopus search was performed to select articles that quantified and compared different neurosurgical approaches in the preclinical setting. The basic characteristics that anatomically define a surgical approach were defined. Each study was analyzed for measured features and quantification method and technique. Ninety-nine papers, published from 1990 to 2013, were included in this review. A heterogeneous use of terms to define the features of a surgical approach was evident. Different methods to study these features have been reported; they are generally based on quantification of distances, angles, and areas. Measuring tools have evolved from the simple ruler to frameless stereotactic devices. The reported methods have each specific advantages and limits; a common limitation is the lack of 3D visualization and surgical volume quantification. There is a need for a uniform nomenclature in anatomical studies. Frameless stereotactic devices provide a powerful tool for anatomical studies. Volume quantification and 3D visualization of the surgical approach is not provided with most available methods.
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Gardner PA, Vaz-Guimaraes F, Jankowitz B, Koutourousiou M, Fernandez-Miranda JC, Wang EW, Snyderman CH. Endoscopic Endonasal Clipping of Intracranial Aneurysms: Surgical Technique and Results. World Neurosurg 2015; 84:1380-93. [PMID: 26117084 DOI: 10.1016/j.wneu.2015.06.032] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 06/15/2015] [Accepted: 06/16/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Microsurgical clipping of intracranial aneurysms requires meticulous technique and is usually performed through open approaches. Endoscopic endonasal clipping of intracranial aneurysms may use the same techniques through an alternative corridor. The aim of this article is to report a series of patients who underwent an endoscopic endonasal approach (EEA) for microsurgical clipping of intracranial aneurysms. METHODS We conducted a retrospective chart review. Surgical outcome and complications were noted. The conceptual application and the technical nuances of these procedures are discussed. RESULTS Ten patients underwent EEA for clipping of 11 intracranial aneurysms arising from the paraclinoidal internal carotid artery (n = 9) and vertebrobasilar system (n = 2). The internal carotid artery aneurysms projected medially, whereas the vertebrobasilar artery aneurysms were directly ventral to the brainstem with low-lying basilar apices. One patient required craniotomy for distal control given the size and thrombosed nature of the aneurysm. Proximal and distal vascular control with direct visualization of the aneurysm was obtained in all patients. In all cases, aneurysms were completely occluded. Among complications, 3 patients had postoperative cerebrospinal fluid leakage and 2 other patients had meningitis. Two patients suffered lacunar strokes. One recovered completely and the other remains with mild disabling symptoms. CONCLUSIONS EEAs can provide direct access for microsurgical clipping of rare and carefully selected intracranial aneurysms. The basic principles of cerebrovascular surgery have to be followed throughout the procedure. These surgeries require a skull base team with a neurosurgeon well versed in both endoscopic endonasal and cerebrovascular surgery, working in concert with an otolaryngologist experienced in skull base endoscopy and reconstruction.
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Affiliation(s)
- Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Francisco Vaz-Guimaraes
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian Jankowitz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Maria Koutourousiou
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Lateral transzygomatic middle fossa approach and its extensions: surgical technique and 3D anatomy. Clin Neurol Neurosurg 2014; 130:33-41. [PMID: 25576883 DOI: 10.1016/j.clineuro.2014.12.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 11/04/2014] [Accepted: 12/20/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Various approaches to lesions involving the middle fossa and cavernous sinus (CS), with and without posterior fossa extension have been described. In the present study, we describe the surgical technique for the extradural lateral tranzygomatic middle fossa approach and its extensions, highlight relevant 3D anatomy. METHODS Simulations of the lateral transzygomatic middle fossa approach and its extensions were performed in four silicon-injected formalin fixed cadaveric heads. The step-by-step description and relevant anatomy was documented with 3D photographs. RESULT The lateral transzygomatic middle fossa approach is particularly useful for lesions involving the middle fossa with and without CS invasion, extending to the posterior fossa and involving the clinoidal region. This approach incorporates direct lateral positioning of patient, frontotemporal craniotomy with zygomatic arch osteotomy, extradural elevation of the temporal lobe, and delamination of the outer layer of the lateral CS wall. Extradural drilling of the sphenoid wing and anterior clinoid process allows entry into the CS through the superior wall and exposure of the clinoidal segment of the ICA. Posteriorly, drilling the petrous apex allows exposure of the ventral brainstem from trigeminal to facial nerve and can be extended to the interpeduncular fossa by division of the superior petrosal sinus. CONCLUSION The present study illustrates 3D anatomical relationships of the lateral transzygomatic middle fossa approach with its extensions. This approach allows wide access to different topographic areas (clinoidal region and clinoidal ICA, the entire CS, and the posterior fossa from the interpeduncular fossa to the facial nerve) via a lateral trajectory. Precise knowledge of technique and anatomy is necessary to properly execute this approach.
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