Various patterns of the middle cerebral vein and preservation of venous drainage during the anterior transpetrosal approach

The trans-sylvian trans-petrosal "half & half" approach-a how I do it

BACKGROUND

Petroclival meningiomas are one of the most challenging tumors to be operated in the realm of neurosurgery. Many approaches have been developed over the years.

METHOD

The authors describe the Half & Half (H&H) approach whose main indication is petroclival meningiomas with suprasellar extension. The part of the tumor located above CN III and in the retrochiasmatic space is addressed through a trans-sylvian, while the petroclival portion is through an extradural anterior petrosectomy approach. The wide surgical corridor given by this approach allows extensive tumor resection while avoiding the risk associated with the manipulation of intracavernous neurovascular structures.

CONCLUSION

The H&H approach is an effective strategy to maximize the safe resection of petroclival meningiomas.

Anterior Petrosectomy With Intertentorial Approach

BACKGROUND AND OBJECTIVES

The extradural anterior petrosal approach (EAPA) can present a challenge because it deals with critical structures in a narrow, confined corridor. It is associated with several potential approach-related risks including temporal lobe and venous injuries. Tentorial peeling has the potential to largely eliminate these risks during the approach and may offer more options for tailoring the dural opening to the anatomic region that one wants to expose.

METHODS

Anatomic dissections of five adult injected non-formalin-fixed cadaveric heads were performed. Anterior petrosectomy with intertentorial approach (APIA) through a tentorial peeling was completed. Step-by-step documentation of the cadaveric dissections and diagrammatic representations are presented along with an illustrative case.

RESULTS

Tentorial peeling separates the tentorium into a temporal tentorial leaf and posterior fossa tentorial leaf, adding a fourth dural layer to the three classic ones described during a standard EAPA. This opens out the intertentorial space and offers more options for tailoring the dural incisions specific to the pathology being treated. This represents a unique possibility to address brainstem or skull base pathology along the mid- and upper clivus with the ability to keep the entire temporal lobe and basal temporal veins covered by the temporal tentorial leaf. The APIA was successfully used for the resection of a large clival chordoma in the illustrative case.

CONCLUSION

APIA is an interesting modification to the classic EAPA to reduce the approach-related morbidity. The risk reduction achieved is by eliminating the exposure of the temporal lobe while maintaining the excellent access to the petroclival region. It also provides several options to tailor the durotomies based on the localization of the lesion.

The Basal or Sphenopetrosal Superficial Middle Cerebral Vein Type

Background and Objectives: The adult superficial middle cerebral vein (SMCV) commonly drains into the middle cranial fossa. However, different embryonic types persist, in which the SMCV drains into the lateral sinus. The basal type of SMCV coursing on the middle fossa floor is a scarce variant. Materials and Methods: During a retrospective study of archived computed tomography angiography (CTA) and magnetic resonance angiography (MRA) files, three rare adult cases of the basal or sphenopetrosal type of SMCV were found and further documented. Results: In the first case, which was evaluated via CTA, the basal type of SMCV formed a sagittal loop. It continued on the middle fossa floor, over a dehiscent tegmen tympani, to drain into the lateral sinus. In the second case, documented via MRA, the basal type of SMCV's anterior loop was in the coronal plane and closely related to the internal carotid artery and the cavernous sinus. It continued with the basal segment over a dehiscent glenoid fossa of the temporomandibular joint (TMJ). In the third case, documented via CTA, the initial cerebral part of the SMCV had a large fenestration. The middle fossa floor coursed within a well-configured sulcus of the SMCV and received a tributary through the tympanic roof. Its terminal had a tentorial course. Conclusions: Beyond the fact that such rare variants of the SMCV can unexpectedly interfere with specific approaches via the middle fossa, dehiscences of the middle fossa floor beneath such variants can determine otic or TMJ symptoms. Possible loops and fenestrations of the SMCV should be considered and documented preoperatively.

Middle cranial fossa non-cavernous sinus dural arteriovenous fistulas: 20 years of experience

Non-cavernous sinus (CS) dural arteriovenous fistulas (DAVFs) involving the sphenoid bone are rare entities that are easily confused with one another due to the complex structure and high variability of the venous system around the middle cranial fossa. We present a large retrospective study on middle cranial fossa non-CS DAVFs and review the literature on DAVF treatment in this location as well as relative anatomy. 15 patients had DAVFs involving the lesser sphenoid wing and 11 patients had DAVFs involving the greater sphenoid wing. Six patients presented with intracranial hemorrhage or subarachnoid hemorrhage (23.1%, 6/26). The most common symptoms were eye symptoms (38.5%, 10/26). Nineteen patients were treated with trans-arterial embolization (TAE) using liquid embolic agents and two patients were treated with transvenous embolization (TVE) using Onyx or in combination with coils. Surgical disconnection of the drainage veins was performed in five patients, with three cases experiencing unsuccessful TAE. Anatomic cure was achieved in 92.3% of the patients (24/26). Twelve patients had DSA and clinical follow-up from 3 to 27 months. There was one recurrence (8.3%) of the fistula in the patient two months after the initial complete occlusion. The majority of patients can be cured endovascularly. Laterocavernous sinus DAVFs may not be embolized by transvenous approach via the cavernous sinus because there is often no connection between them in most patients. A small percentage of patients may require surgical ligation to be cured.

Evaluation of Venous Structures that Are Involved in Transsylvian Approach Using 3D Rotational Venography

In the transsylvian (TS) approach, as characterized by clipping surgery, the presurgical visualization of the superficial middle cerebral vein (SMCV) can help change the surgical approach to ensure safe microsurgery. Nevertheless, identifying preoperatively the venous structures that are involved in this approach is difficult. In this study, we investigated the venous structures that are involved in the TS approach using three-dimensional (3D) rotational venography (3D-RV) and evaluated the effectiveness of this method for presurgical simulation. Patients who underwent 3D-RV between August 2018 and June 2020 were involved in this retrospective study. The 3D-RV and partial maximum intensity projection images with a thickness of 5 mm were computationally reconstructed. The venous structures were subdivided into the following three portions according to the anatomic location: superficial, intermediate, and basal portions. In the superficial portion, predominant frontosylvian veins were observed on 31 (41%) sides, predominant temporosylvian veins on seven (9%) sides, and equivalent fronto- and temporosylvian veins on 28 (37%) sides. The veins in the intermediate (deep middle cerebral and uncal veins) and basal portions (frontobasal bridging veins) emptied into the SMCV on 57 (75%) and 34 (45%) sides, respectively. The 3D-RV images were highly representative of the venous structures observed during microsurgery. In this study, 3D-RV was utilized to capture the details of the venous structures from the superficial to the deep portions. Presurgical simulation of the venous structures that are involved in the TS approach using 3D-RV may increase the safety of microsurgical approaches.

Anatomical variations and flow alterations of the uncal vein and its clinical implications in petroclival meningiomas

BACKGROUND

The Uncal vein (UV), downstream of the deep middle cerebral vein (DMCV), has a similar drainage pattern to the superficial middle cerebral vein (SMCV) and may be involved in venous complications during the anterior transpetrosal approach (ATPA). However, in petroclival meningioma (PCM), where the ATPA is frequently used, there are no reports evaluating drainage patterns of the UV and the risk of venous complications associated with the UV during the ATPA.

METHODS

Forty-three patients with petroclival meningioma (PCM) and 20 with unruptured intracranial aneurysm (control group) were included. Preoperative digital subtraction angiography was used to evaluate UV and DMCV drainage patterns on the side of the tumor and bilaterally in patients with PCM and the control group, respectively.

RESULTS

In the control group, the DMCV drained to the UV, UV and BVR, and BVR in 24 (60.0%), eight (20.0%), and eight (20.0%) hemispheres, respectively. Conversely, the DMCV in the patients with PCM drained to the UV, UV and BVR, and BVR in 12 (27.9%), 19 (44.2%), and 12 (27.9%) patients, respectively. The DMCV was more likely to be drained to the BVR in the PCM group (p < 0.01). In three patients with PCM (7.0%), the DMCV drained only to the UV, and furthermore, the UV drained to the pterygoid plexus via the foramen ovale, posing a risk for venous complications during the ATPA.

CONCLUSIONS

In the patients with PCM, the BVR functioned as a collateral venous pathway of the UV. Preoperative evaluation of the UV drainage patterns is recommended to reduce venous complications during the ATPA.

Surgical morbidity of the extradural anterior petrosal approach: the Lariboisière experience

OBJECTIVE

Concerns about the approach-related morbidity of the extradural anterior petrosal approach (EAPA) have been raised, especially regarding temporal lobe and venous injuries, hearing impairment, facial nerve palsy, cerebrospinal fluid fistula, and seizures. There is lack in the literature of studies with detailed analysis of surgical complications. The authors have presented a large series of patients who were treated with EAPA, focusing on complications and their avoidance.

METHODS

The authors carried out a retrospective review of patients who underwent EAPA at their institution between 2012 and 2021. They collected preoperative clinical characteristics, operative reports, operative videos, findings on neuroimaging, histological diagnosis, postoperative course, and clinical status at last follow-up. For pathologies without petrous bone invasion, the amount of petrous apex drilling was calculated and classified as low (< 70% of the volume) or high (≥ 70%). Complications were dichotomized as approach related and resection related.

RESULTS

This study included 49 patients: 26 with meningiomas, 10 brainstem cavernomas, 4 chondrosarcomas, 4 chordomas, 2 schwannomas, 1 epidermoid cyst, 1 cholesterol granuloma, and 1 osteoblastoma. The most common approach-related complications were temporal lobe injury (6.1% of patients), seizures (6.1%), pseudomeningocele (6.1%), hearing impairment (4.1%), and dry eye (4.1%). Approach-related complications occurred most commonly in patients with a meningioma (p = 0.02) and Meckel's cave invasion (p = 0.02). Gross-total or near-total resection was correlated with a higher rate of tumor resection-related complications (p = 0.02) but not approach-related complications (p = 0.76). Inferior, lateral, and superior tumoral extension were not correlated with a higher rate of tumor resection-related complications. No correlation was found between high amount of petrous bone drilling and approach- or resection-related complications.

CONCLUSIONS

EAPA is a challenging approach that deals with critical neurovascular structures and demands specific skills to be safely performed. Contrary to general belief, its approach-related morbidity seems to be acceptable at dedicated skull base centers. Morbidity can be lowered with careful examination of the preoperative neuroradiological workup, appropriate patient selection, and attention to technical details.

Comprehensive microsurgical anatomy of the middle cranial fossa: Part II-neurovascular anatomy

In order to master the surgical approaches to the middle cranial fossa, the surgeon needs to understand the relevant bony anatomy. However, she/he also needs to have a clear and sound understanding of the neural and vascular anatomy because, oftentimes, the osseous anatomy (except for the optic apparatus) should be removed to expose and protect the neurovascular anatomy. This is the second of a two-part article discussing the neurovascular anatomy of the middle cranial fossa. A brief discussion of the surgical approaches follows.

Surgical Strategy in Modification of the Transpetrosal Approach to Avoid Postoperative Venous Complications: A Report of 74 Consecutive Cases

BACKGROUND

The transpetrosal approach is a complex skull base procedure with a high risk of complications, particularly caused by injury of the venous system. It is in part related to variability of blood outflow pathways and their distinctive patterns in each individual patient.

OBJECTIVE

To evaluate outcomes and complications after skull base surgery with use of the petrosal approach modifications, which selection was based on the detailed preoperative assessment of venous drainage patterns.

METHODS

Overall, 74 patients, who underwent surgery via the transpetrosal approach at our institution between 2000 and 2017, were included in this study. In all cases, the venous drainage pattern was assessed preoperatively and categorized according to the predominant blood outflow pathway into four types as previously suggested by Hacker: (1) sphenoparietal sinus (SpPrt), (2) sphenobasal vein (SpB), (3) sphenopetrosal sinus (SpPS), and (4) cortical. The blood outflow through the bridging petrosal vein and the vein of Labbé was also taken into consideration. In patients with SpPrt- and a cortical-type venous drainage, the transpetrosal approach was used in a standard way. In patients with SpB-type venous drainage, limited extradural anterior petrosectomy was combined with intradural anterior petrosectomy after dural opening, superior petrosal sinus transection, tentorial cutting, Meckel's cave opening, and trigeminal nerve mobilization. In patients with SpPS-type venous drainage, after standard petrosectomy, dural opening, and tentorial cutting, SpPS ligation was done followed by 2-week interval before staged definitive tumor resection.

RESULTS

Gross total, near-total, and subtotal resection of the lesion (meningioma, 48 cases; retrochiasmatic craniopharyngioma, 11 cases; brain stem cavernoma, 7 cases; other tumors, 8 cases) was achieved in 30 (40.5%), 24 (32.4%), and 20 (27.0%) patients, respectively. Postoperative complications that were possibly related to venous compromise were noted in 18 patients (24.3%), but neither one was major. Of these 18 patients, 9 were symptomatic, but all symptoms-aphasia (4 cases), seizures (2 cases), and confusion (3 cases)-fully resolved after conservative treatment. Overall, 13 patients, including 4 symptomatic, had signal changes on T2-weighted brain MRI, which were permanent only in 3 cases (all asymptomatic).

CONCLUSION

Our suggested surgical strategy can be applied to any type of the venous drainage pattern. Preoperative evaluation and intraoperative preservation of the blood outflow pathways are crucial means for safe and effective application of the transpetrosal approach.

Magnetic resonance analysis of deep cerebral venous vasospasm after subarachnoid hemorrhage in rabbits

Objective

Arterial spasm is proved to be an inducer of cerebral ischemia and cerebral infarction, while when a venous spasm occurs, cerebral edema is seen to be caused by a disturbance in cerebral blood flow. However, it is unclear and unproven whether venous spasm occurs after subarachnoid hemorrhage (SAH). To provide the theoretical basis for treating cerebral vasospasm after SAH, magnetic resonance imaging (MRI) was employed to observe the changes in the diameter of deep cerebral veins in rabbits after SAH.

Methods

Fourteen New Zealand rabbits were randomly divided into the SAH group (n = 10) and the normal saline group (NS group, n = 4). Specifically, the SAH models were established by the ultrasound-guided double injections of blood into cisterna magna. Moreover, the MRI was performed to observe the changes in the diameter of deep cerebral veins (internal cerebral vein, basilar vein, and great cerebral vein) and basilar artery before modeling (0 d) and 1, 3, 5, 7, 9, and 11 d after modeling.

Results

In the SAH group, the diameter of the basilar artery showed no evident change on the 1st d. However, it became narrower obviously on the 3rd d and 5th d, and the stenosis degree was more than 30%. The diameter gradually relieved from 7th to 9th d, and finally returned to normal on the 11th d. Moreover, the diameter of the internal cerebral vein significantly narrowed on the 1st d, the stenosis degree of which was 19%; the stenosis then relieved slightly on the 3rd d (13%), reached the peak (34%) on the 5th d, and gradually relieved from 7th d to 11th d. Moreover, the stenosis degree of the basilar vein was 18% on the 1st d, 24% on the 3rd d, and reached the peak (34%) on the 5th d.

Conclusion

After SAH in rabbits, the cerebral vasospasm was seen to occur in the basilar artery, and likewise, spasmodic changes took place in the deep cerebral vein. Furthermore, the time regularity of spasmodic changes between the cerebral vein and basilar artery was of significant difference, indicating that the venous vasospasm resulted in active contraction.

A New Classification of the Anatomical Variations of Labbé’s Inferior Anastomotic Vein

(1) Background: The inferior anastomotic vein of Labbé (LV) courses on the temporal lobe, from the sylvian fissure towards the tentorium cerebelli and finishes at the transverse sinus (TS). The importance of the LV topography is related to skull base neurosurgical approaches. Based on the hypothesis of the existence of as yet unidentified anatomical possibilities of the LV, we aimed through this research to document the superficial venous topographic patterns at the lateral and inferior surfaces of the temporal lobe. (2) Methods: A retrospective cohort of 50 computed tomography angiograms (CTAs) of 32 males and 18 females was documented. (3) Results: Absent (type 0) LVs were found in 6% of cases. Anterior (temporal, squamosal–petrosal–mastoid, type 1) LVs were found in 12% of cases. LVs with a posterior, temporoparietal course (type 2) were found to be bilateral in 46% of cases and unilateral in 36% of cases. Type 3 LVs (posterior, parietooccipital) were found to be bilateral in 8% and unilateral in 32% of cases. In 24% of cases, duplicate LVs were found that were either complete or incomplete. A quadruplicate LV was found in a male case. On 78 sides, the LV drained either into a tentorial sinus or into the TS. (4) Conclusions: The anatomy of the vein of Labbé is variable in terms of its course, the number of veins and the modality of drainage; thus, it should determine personalized neurosurgical and interventional approaches. A new classification of the anatomical variations of Labbé’s vein, as detected on the CTAs, is proposed here (types 0–3).

Anterior transpetrosal approach: experiences in 274 cases over 33 years. Technical variations, operated patients, and approach-related complications

OBJECTIVE

The anterior transpetrosal approach (ATPA) was initially reported in 1985. The authors' institution has 274 case records of surgery performed with the ATPA during the period from 1984 to 2017. Although many technical advances and modifications in the ATPA have occurred over those 33 years, to the authors' knowledge no articles to date have reported a detailed analysis of variations and complications of the ATPA. In this study, the authors analyzed their patient series to elucidate improvements over time in ATPA methodology while highlighting unresolved problems and evaluating how to avoid surgical complications.

METHODS

All surgical cases (274 patients) using the ATPA at the authors' institution during the period from 1984 to 2017 were analyzed retrospectively using charts, clinical summaries, operative records, and operative videos. Obtained parameters were patient age and sex, diagnosis, size of tumors, location of disease, operative date, neurological symptoms before and after surgery, radiographically identified brain injury, and other surgical complications. The most common diagnosis was petroclival meningioma (n = 158), followed by trigeminal schwannoma (n = 32), chordoma (n = 25), epidermoid tumor (n = 21), other tumor (n = 27), aneurysm (n = 6), and other (n = 5).

RESULTS

The original ATPA was performed in 239 cases. In an additional 35 cases, a modified ATPA was performed. Zygomatic osteotomy with ATPA was a common modification that was used in 19 of the 35 cases to decrease retraction damage to the temporal lobe for high-positioned tumors. Brain injury by temporal lobe retraction without venous hemorrhage still occurred in 8 of the 19 cases (3.1%) with surgical death in 1 of these cases (0.4%) of reoperation with sacrifice of the petrosal vein. Symptomatic CSF leak was the most frequent complication noted and was observed in 35 cases (13.5%). In most of these cases the patients were cured by observation or lumbar drain, but in 6 cases (17.1%) reoperation was needed. Facial nerve damage related to surgical approach decreased from 6.2% to 3.5% after 2010; however, the incidence of CSF leaks (13.5%) has not improved.

CONCLUSIONS

There have been several modifications and advancements made in the ATPA to increase tumor removal and decrease surgical complications. However, complications related to surgical approach occurred, such as venous occlusion-related brain injury and facial nerve damage at pyramid resection. CSF leak remained an unsolved problem related to the ATPA procedures. Preoperative assessment of venous variation of the middle fossa, pneumatization of the temporal bone, and intraoperative monitoring of cranial nerves are important procedures to decrease these complications.

Evolution of microneurosurgical anatomy with special reference to the history of anatomy, surgical anatomy, and microsurgery: historical overview

This article reviews the evolution of microneurosurgical anatomy (MNA) with special reference to the development of anatomy, surgical anatomy, and microsurgery. Anatomy can be said to have started in the ancient Greek era with the work of Hippocrates, Galen, and others as part of the pursuit of natural science. In the sixteenth century, Vesalius made a great contribution in reviving Galenian knowledge while adding new knowledge of human anatomy. Also in the sixteenth century, Ambroise Paré can be said to have started modern surgery. As surgery developed, more detailed anatomical knowledge became necessary for treating complicated diseases. Many noted surgeons at the time were also anatomists eager to spread anatomical knowledge in order to enhance surgical practice. Thus, surgery and anatomy developed together, with advances in each benefiting the other. The concept of surgical anatomy evolved in the eighteenth century and became especially popular in the nineteenth century. In the twentieth century, microsurgery was introduced in various surgical fields, starting with Carl O. Nylen in otology. It flourished and became popularized in the second half of the century, especially in the field of neurosurgery, following Jacobson and Suarez's success in microvascular anastomosis in animals and subsequent clinical application as developed by M.G. Yasargil and others. Knowledge of surgical anatomy as seen under the operating microscope became important for surgeons to perform microneurosurgical procedures accurately and safely, which led to the fuller development of MNA as conducted by many neurosurgeons, among whom A.L. Rhoton, Jr. might be mentioned as representative.

Surgical outcomes of anterior cerebellopontine angle meningiomas using the anterior transpetrosal approach compared with the lateral suboccipital approach

BACKGROUND

Anterior transpetrosal approach (ATPA) and lateral suboccipital approach (LSO) are the major surgical approaches for cerebellopontine angle (CPA) meningiomas. Particularly, anterior CPA meningiomas are challenging lesions to be treated surgically. To date, only a few studies have directly compared the outcomes of both approaches focusing on the anterior CPA meningiomas.

METHODS

For the comparative analysis, anterior CPA meningiomas that were eligible for both APTA and LSO were collected in our hospital from April 2005 to March 2017. Anterior CPA meningiomas targeted for this study were defined as follows: (1) without cavernous sinus, clivus, and middle cranial fossa extension, (2) the posterior edge is 1 cm behind the posterior wall of the internal auditory canal, and (3) the inferior edge is above the jugular tuberculum. Based on these criteria, the operative outcomes of 17 patients and 13 patients who were operated via ATPA and LSO were evaluated.

RESULTS

The complication rate of the LSO group was significantly higher than that of the ATPA group (30.7% vs. 0%, p = 0.033). The removal rate did not differ between the ATPA and LSO groups (97.35% vs. 99.23%, p = 0.12). The operative time was significantly shorter in the LSO group than in the ATPA group (304.3 min vs. 405.8 min, p = 0.036).

CONCLUSIONS

Although the LSO is more widely used for CPA meningiomas, ATPA is also considered for these anterior CPA meningiomas.

Bridging vein and tentorial sinus in the subtemporal corridor during the anterior transpetrosal approach

BACKGROUND

The bridging vein (BV) and the tentorial sinus (TenS) are important venous structures in neurological surgery. These venous structures during the anterior transpetrosal approach (ATPA) have not been reported. The objective of this study is to examine the BV and the TenS in the subtemporal corridor during the ATPA and propose a technique to identify the BV preoperatively.

METHODS

This study included 126 patients treated via the ATPA. The BV and the TenS located in the operative fields were analyzed. Furthermore, in the preoperative evaluation, the cross-sectional shapes of the intradural vein and the interdural sinus were analyzed by curved planar reconstruction (CPR), and the flattening rate was calculated. Flattening rate = (a-b)/a = 1-b/a (a: long radius, b: short radius).

RESULTS

Seventeen BVs and 18 TenS were identified. The bridging site was divided into two groups: tentorial and middle fossa. The middle fossa group was divided into three subgroups: cavernous sinus, middle fossa dural sinus, and middle fossa dural adherence. Five isolated TenS were sacrificed and no venous complications were observed. The mean flattening rate was 0.13 in the intradural vein and 0.51 in the interdural sinus, respectively (P = 0.0003).

CONCLUSIONS

We showed classification of the BV, and preservation of the BV and TenS during the ATPA. Furthermore, we found that the interdural sinus was significantly flatter than the intradural veins. Measuring the flattening rate by CPR may be useful to identify BVs preoperatively.

Superficial temporal artery-superior cerebellar artery bypass and trapping of a fusiform aneurysm using intradural anterior petrosectomy: technical case report and anatomical study

Aneurysms at the distal portion of the superior cerebellar artery (SCA) are very rare. Because of the deep location and a propensity for nonsaccular morphology, aneurysm trapping or endovascular occlusion of the parent artery are the usual treatment options, which are associated with varying risks of ischemic complications. The authors report on a 60-year-old woman who had a 3.5-mm unruptured aneurysm in the lateral pontomesencephalic segment of the SCA with a significant interval growth to 8 mm. Direct surgical intervention comprising trapping of the aneurysm through a subtemporal approach and intradural anterior petrosectomy combined with revascularization of the distal SCA using the superficial temporal artery (STA) was performed. This approach provided sufficient space for the bypass instruments to be introduced into the deep surgical field at a more favorable angle to enhance microscopic visualization of the anastomosis with minimal retraction of the temporal lobe. The patient was discharged with no neurological deficit. Preservation of the blood flow in the distal SCA should be attempted to minimize the risk of ischemic injury, particularly when the aneurysms arise in the anterior or lateral segment of the SCA. The authors demonstrate the safety and effectiveness of the intradural anterior petrosectomy for STA-SCA bypass along with a relevant anatomical study.

Extended exposure of the petroclival junction: The combined anterior transpetrosal and subtemporal/transcavernous approach

Background:

The combined anterior transpetrosal and subtemporal/transcavernous (atsta) approach to the petroclival junction provides a wide exposure facilitating resection of large tumor lesions such as petroclival mengiomas, chondrosarcomas, or chordomas. In this article we provide technical instructions on the approach with anatomical consideration and a literature review of previous applications of this approach.

Methods:

The combined approach was performed in two cadaveric specimen and relevant anatomical aspects were studied. Additionally, the authors performed a review of the literature focusing on indications, neurologic outcome, and complications associated with the technique.

Results:

A combined atsta approach offers a wide exposure of the crus cerebrum, pons, basal temporal lobe, cranial nerves III to VII/VIII, posterior cerebral artery (PCA), superior cerebellar artery (SCA), basilar artery (BA), anterior inferior cerebellar artery (AICA), and posterior communicating artery (Pcom). It has been successfully applied with acceptable morbidity and mortality rates, mainly for (spheno-) petroclival meningiomas.

Conclusion:

The combined approach studied here is a useful skull base approach to the petroclival junction and can be applied to treat large or complex pathologies of the region. Detailed anatomical knowledge is essential.

Analysis of various tracts of mastoid air cells related to CSF leak after the anterior transpetrosal approach

OBJECTIVE

The anterior transpetrosal approach (ATPA) was established in 1984 and has been particularly effective for petroclival tumors. Although some complications associated with this approach, such as venous hemorrhage in the temporal lobe and nervous disturbances, have been resolved over the years, the incidence rate of CSF leaks has not greatly improved. In this study, some varieties of air cell tracts that are strongly related to CSF leaks are demonstrated. In addition, other pre- and postoperative risk factors for CSF leakage after ATPA are discussed.

METHODS

Preoperative and postoperative target imaging of the temporal bone was performed in a total of 117 patients who underwent ATPA, and various surgery-related parameters were analyzed.

RESULTS

The existence of air cells at the petrous apex, as well as fluid collection in the mastoid antrum detected by a postoperative CT scan, were possible risk factors for CSF leakage. Tracts that directly connected to the antrum from the squamous part of the temporal bone and petrous apex, rather than through numerous air cells, were significantly related to CSF leak and were defined as “direct tract.” All patients with a refractory CSF leak possessed “unusual tracts” that connected to the attic, tympanic cavity, or eustachian tube, rather than through the mastoid antrum.

CONCLUSIONS

Preoperative assessment of petrous pneumatization types is necessary to prevent CSF leaks. Direct and unusual tracts are particularly strong risk factors for CSF leaks.

Evaluation of Venous Drainage Patterns for Skull Base Meningioma Surgery

The evaluation of venous drainage patterns prior to surgery for skull base meningioma is important owing to their deep location and the vulnerability of surrounding vascular structures. In recent years, the microsurgical skull base approach has matured as a surgical technique, making it an important option for reducing complications related to skull base meningioma surgery. In addition, knowledge of the venous anatomy can prevent venous drainage route disturbance and potentially life-threatening complications. Hence, this topic review aimed to provide an overview of normal venous anatomy as it relates to the microsurgical skull base approach, discuss known changes in venous drainage routes that are associated with the progression of skull base meningioma and the selection of an appropriate operative approach with the highest likelihood of preserving venous drainage structures.

Visualization of the tentorial innervation of human dura mater

Posterior projections of the ophthalmic division of the trigeminal nerve (the ophthalmic nerve) are distributed in the tentorium cerebelli as recurrent meningeal branches. We investigated the morphological tentorial distribution of the ophthalmic nerve. Fifty-two sides of the tentorium cerebelli and adjacent dura mater obtained from 29 human specimens were stained using Sihler's method to examine the nerve fibres in the dural sheets. The innervation patterns of the tentorium cerebelli were classified into the following four types according to their distributions: Type 1, where nerve fibres projected to both the straight and transverse sinuses; Type 2, where nerve fibres projected only to the transverse sinus and lateral convexity; Type 3, where nerve fibres projected medially only to the straight sinus and the posterior part of the falx cerebri; and Type 4, where the nerve fibres terminated within the tentorium cerebelli. Images of the tentorium cerebelli were superimposed to identify areas of dense innervation. The incidence rates of Types 1-4 were 71.2% (n = 37), 21.2% (n = 11), 3.8% (n = 2) and 3.8% (n = 2), respectively. More branches of nerve fibres traversed towards the transverse sinus posterolaterally than towards the straight sinus medially. The space between the anterior half of the straight sinus and the medial tentorial notch can be considered a safe surgical area where innervation is scarce. The posterior part of the falx cerebri was innervated by the ophthalmic nerve that traversed to the straight sinus. The parietal branches of the middle meningeal artery in the lateral convexity that were projected orthogonally by the ophthalmic nerve traversed the transverse sinus, implicating their vulnerability and possible sensitivity under physiological or neurosurgical conditions. This study has revealed the macroscopic tentorial innervation of the dura mater in humans, which could be useful information for both neurosurgeons and neurologists.

Intraspinosum Middle Meningeal Artery Ligation: A Simple Technique to Control Bleeding in the Middle Fossa During the Anterior Transpetrosal Approach

BACKGROUND

Although the greater superficial petrosal nerve (GSPN) is an important landmark of the anterior transpetrosal approach (ATPA), bleeding from the interdural space around the foramen spinosum (FS), the GSPN, and the foramen ovale impedes the identification of the GSPN, during epidural dissection in the ATPA.

OBJECTIVE

To describe the technique of intraspinosum middle meningeal artery (MMA) ligation, which enables us to control bleeding from the interdural space.

METHODS

During epidural dissection, we identified the FS and partially drilled the lateral side of the FS. Next, we cut the convergence site of the neurovascular structures such as the MMA, middle meningeal vein, and the meningeal branch of the mandibular nerve with the periosteal dura within the FS and continued dural detachment epidurally to expose the petrous apex. Bleeding control around the FS and postoperative facial nerve paresis were assessed for 96 patients treated with the ATPA. Additionally, histological study was performed around the FS using Masson's trichrome stain.

RESULTS

In all cases, in which this technique was used, bleeding from the interdural space was well controlled and no persistent facial nerve paresis was identified. In the histological study, we confirmed that the MMA, the middle meningeal vein, and the meningeal branch of the mandibular nerve converged into the FS and many venous channels existed in the interdural space around the FS and the foramen ovale.

CONCLUSION

Intra-FS MMA ligation is an effective method for control of bleeding from the interdural space of the middle fossa during the ATPA.

The Analysis of the Petrosal Vein to Prevent Venous Complications During the Anterior Transpetrosal Approach in the Resection of Petroclival Meningioma

BACKGROUND

The anterior transpetrosal approach (ATPA) has been used in the resection of petroclival meningioma (PCM) for more than 20 years. Although PCM sometimes involves the petrosal vein and its preservation has been an important issue, the precise risk of petrosal vein sacrifice and subsequent venous complications associated with the use of the ATPA in patients with PCM has not yet been elucidated.

METHODS

We used computed tomographic (CT) digital subtraction venography (DSV) in the retrospective analysis of the petrosal vein and its tributaries in patients with PCM before and after surgery. We also examined the incidence of postoperative venous complications in each of the patients.

RESULTS

The detection rate of the petrosal vein and some of its tributaries on CT-DSV in patients with PCM was significantly lower than that in controls. Preoperatively, CT-DSV detected the petrosal vein in 71.8% of patients with PCM. The detected petrosal veins were preserved after the operation in 64.3% of these patients. No venous complications involving petrosal vein were observed in any of the patients. Anastomosis between the petrosal vein and the basal vein via the pontotrigeminal vein was found to be significantly more developed in the patients with PCM compared with the controls.

CONCLUSIONS

Our study demonstrated that the ATPA could be performed safely on patients with PCM from the viewpoint of venous preservation. Preoperative CT-DSV is important for assessing the petrosal vein and its tributaries to facilitate a safer operation.

Poor diagnostic accuracy of transcranial motor and somatosensory evoked potential monitoring during brainstem cavernoma resection

OBJECTIVE

Microsurgical resection of brainstem cavernomas carries a high risk of new postoperative morbidity such as cranial nerve, motor and sensory deficits as well as functional deterioration. Intraoperative monitoring is used to avoid impending damage to these highly eloquent tracts. However, data on neurophysiological monitoring during resection of brainstem cavernomas are lacking.

METHODS

Consecutive patients with brainstem cavernomas who underwent surgical removal from June 2007 to December 2014 were retrospectively analysed. Transcranial motor-evoked potential (MEP) and somatosensory-evoked potential (SSEP) monitorings were performed in all cases. The evoked potential (EP) monitoring data were reviewed and related to new postoperative motor and sensory deficits and postoperative imaging. Clinical outcomes were assessed during follow-up.

RESULTS

Twenty-six consecutive patients with brainstem cavernoma underwent 27 surgical resections within this study. MEP and SSEP monitoring was technically feasible in 26 and 27 cases, respectively. MEP sensitivity and specificity were 33 and 88 %, respectively. MEP positive and negative predictive values were 28 and 78 %, respectively. SSEP sensitivity and specificity were 20 and 81 %, respectively. SSEP positive and negative predictive values were 20 and 81 %, respectively.

CONCLUSION

In continuous MEP and SSEP monitoring during brainstem cavernoma microsurgery, high rates of false-positive and -negative results are encountered, resulting in low positive and relatively high negative predictive values. Careful interpretation of the intraoperative monitoring results is essential in order to avoid potentially unjustified termination of brainstem cavernoma resection.

Frontotemporal epi- and subdural approach to a cavernous sinus tumor for sphenobasal vein preservation--technical case report

In cavernous sinus (CS) surgery, venous complication may occur in some types of venous drainage. The sphenobasal vein (SBV) drains from the superficial middle cerebral vein (SMCV) to the pterygoid venous plexus at the temporal skull base. A frontotemporal epi- and interdural approach (Dolenc approach), which is one of the CS approaches, may damage the SBV's route. We report a case of intracavernous trigeminal schwannoma that contained the SBV and discuss our modified surgical procedure that combined epi- and subdural approaches to preserve the SBV. A 64-year-old man complained of right progressive oculomotor palsy and was referred to our hospital for surgery. MR images revealed a hemorrhagic tumor in the right CS. Three-dimensional venography revealed that the SMCV drained into the pterygoid venous plexus via the SBV. After identifying the first branch of the trigeminal nerve epidurally, we incised the dura linearly along the sylvian fissure and entered the subdural space to visualize the SBV. The incision was continued to the meningeal dura of the lateral wall of the CS along the superior margin of the first branch of the trigeminal nerve, and the Parkinson's triangle was opened from the subdural side. The tumor was grossly totally removed, and the SBV was preserved. In conclusion, a frontotemporal epi- and subdural approach to the intracavernous trigeminal schwannoma can effectively preserve the SBV.