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Rennert RC, Brandel MG, Steinberg JA, Gonda DD, Friedman RA, Fukushima T, Day JD, Khalessi AA, Levy ML. Maturation of the anterior petrous apex: surgical relevance for performance of the middle fossa transpetrosal approach in pediatric patients. J Neurosurg 2022; 136:1090-1096. [PMID: 34534955 DOI: 10.3171/2021.3.jns202648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 03/24/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The middle fossa transpetrosal approach to the petroclival and posterior cavernous sinus regions includes removal of the anterior petrous apex (APA), an area well studied in adults but not in children. To this end, the authors performed a morphometric analysis of the APA region during pediatric maturation. METHODS Measurements of the distance from the clivus to the internal auditory canal (IAC; C-IAC), the distance of the petrous segment of the internal carotid artery (petrous carotid; PC) to the mesial petrous bone (MPB; PC-MPB), the distance of the PC to the mesial petrous apex (MPA; PC-MPA), and the IAC depth from the middle fossa floor (IAC-D) were made on thin-cut CT scans from 60 patients (distributed across ages 0-3, 4-7, 8-11, 12-15, 16-18, and > 18 years). The APA volume was calculated as a cylinder using C-IAC (length) and PC-MPB (diameter). APA pneumatization was noted. Data were analyzed by laterality, sex, and age. RESULTS APA parameters did not differ by laterality or sex. APA pneumatization was seen on 20 of 60 scans (33.3%) in patients ≥ 4 years. The majority of the APA region growth occurred by ages 8-11 years, with PC-MPA and PC-MPB increasing 15.9% (from 9.4 to 10.9 mm, p = 0.08) and 23.5% (from 8.9 to 11.0 mm, p < 0.01) between ages 0-3 and 8-11 years, and C-IAC increasing 20.7% (from 13.0 to 15.7 mm, p < 0.01) between ages 0-3 and 4-7 years. APA volume increased 79.6% from ages 0-3 to 8-11 years (from 834.3 to 1499.2 mm3, p < 0.01). None of these parameters displayed further significant growth. Finally, IAC-D increased 51.1% (from 4.3 to 6.5 mm, p < 0.01) between ages 0-3 and adult, without significant differences between successive age groups. CONCLUSIONS APA development is largely complete by the ages of 8-11 years. Knowledge of APA growth patterns may aid approach selection and APA removal in pediatric patients.
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Affiliation(s)
- Robert C Rennert
- 1Department of Neurological Surgery, University of California, San Diego, La Jolla
| | - Michael G Brandel
- 1Department of Neurological Surgery, University of California, San Diego, La Jolla
| | - Jeffrey A Steinberg
- 1Department of Neurological Surgery, University of California, San Diego, La Jolla
| | - David D Gonda
- 2Department of Neurosciences and Pediatrics, University of California, San Diego, San Diego
| | - Rick A Friedman
- 3Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, University of California, San Diego, La Jolla, California
| | | | - John D Day
- 5Department of Neurosurgery, University of Arkansas, Little Rock, Arkansas
| | - Alexander A Khalessi
- 1Department of Neurological Surgery, University of California, San Diego, La Jolla
| | - Michael L Levy
- 2Department of Neurosciences and Pediatrics, University of California, San Diego, San Diego
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Maturation of the internal auditory canal and posterior petrous bone with relevance to lateral and posterolateral skull base approaches. Sci Rep 2022; 12:3489. [PMID: 35241717 PMCID: PMC8894491 DOI: 10.1038/s41598-022-07343-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/31/2022] [Indexed: 11/18/2022] Open
Abstract
Anatomic knowledge of the internal auditory canal (IAC) and surrounding structures is a prerequisite for performing skull base approaches to the IAC. We herein perform a morphometric analysis of the IAC and surgically relevant aspects of the posterior petrous bone during pediatric maturation, a region well-studied in adults but not children. Measurements of IAC length (IAC-L), porus (IAC-D) and midpoint (IAC-DM) diameter, and distance from the porus to the common crus (CC; P-CC) and posterior petrosal surface (PPS) to the posterior semicircular canal (PSC; PPS-PSC) were made on thin-cut axial CT scans from 60 patients (grouped by ages 0–3, 4–7, 8–11 12–15, 16–18, and > 18 years). IAC-L increased 27.5% from 8.7 ± 1.1 at age 0–3 to 11.1 ± 1.1 mm at adulthood (p = 0.001), with the majority of growth occurring by ages 8–11. IAC-D (p = 0.52) and IAC-DM (p = 0.167) did not significantly change from ages 0–3 to adult. P-CC increased 31.1% from 7.7 ± 1.5 at age 0–3 to 10.1 ± 1.5 mm at adulthood (p = 0.019). PPS-PSC increased 160% from 1.5 ± 0.7 at age 0–3 to 3.9 ± 1.2 mm at adulthood (p < 0.001). The majority of growth in P-CC and PPS-PSC occurred by ages 12–15. Knowledge of these patterns may facilitate safe exposure of the IAC in children.
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Rennert RC, Brandel MG, Steinberg JA, Nation J, Couldwell WT, Fukushima T, Day JD, Khalessi AA, Levy ML. Maturation of the sella turcica and parasellar region: Surgical relevance for anterior skull base approaches in pediatric patients. Clin Neurol Neurosurg 2022; 215:107168. [PMID: 35247690 DOI: 10.1016/j.clineuro.2022.107168] [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: 12/09/2021] [Revised: 01/13/2022] [Accepted: 02/02/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Traditional and extended transnasal transsphenoidal approaches provide direct access to a variety of anterior skull base pathologies. Despite increased utilization of transnasal approaches in children, anatomic studies on pediatric skull base maturation are limited. We herein perform a surgically relevant morphometric analysis of the sella and parasellar regions during pediatric maturation. METHODS Measurements of sellar length (SL), sellar depth (SDp), sellar diameter (SDm), interclinoid distance (ID), intercavernous distance (ICD), and the presence of sphenoid sinus pneumatization (SSP), and sphenoid sinus type (SST) were made on thin-cut CT scans from 60 patients (evenly grouped by ages 0-3, 4-7, 8-11 12-15, 16-18, and >18 years) for analysis. Data were analyzed by sex and age groups using t-tests and linear regression. RESULTS Sella and parasellar parameters did not differ by sex. SL steadily increased from 8.5 ± 1.2 mm to 11.5 ± 1.6 mm throughout development. SDp and SDm increased from 6.0 ± 0.9 mm to 9.3 ± 1.4 mm and 9.0 ± 1.6 mm to 14.4 ± 1.8 mm during maturation, with significant interval growth from ages 16-18 to adult (p < 0.01). ID displayed significant growth from ages 0-3 to 4-7 (18.0 ± 2.4 mm to 20.7 ± 1.9 mm; p = 0.002) and ICD from ages 0-3 to 8-11 (12.0 ± 1.8 mm to 13.5 ± 2.1 mm; p < 0.001), without further significant interval growth. SSP was not seen in patients < 3, but was 100% by ages 8-11. SSTs progressed from conchal/presellar (60% at ages 4-7) to sellar/postsellar (80% at adulthood). CONCLUSION The sella and parasellar regions have varied growth patterns with development. Knowledge of the expected maturation of key anterior skull base structures may augment surgical planning in younger patients.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Michael G Brandel
- Department of Neurological Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Jeffrey A Steinberg
- Department of Neurological Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Javan Nation
- Department of Head and Neck Surgery, University California San Diego, San Diego, CA, United States
| | - William T Couldwell
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, United States
| | | | - John D Day
- Department of Neurosurgery, University of Arkansas, Little Rock, AR, United States
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California, San Diego, La Jolla, CA, United States
| | - Michael L Levy
- Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, CA, United States.
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Petrous bone lesions: surgical implementation and outcomes of extradural subtemporal approach. Acta Neurochir (Wien) 2021; 163:2881-2894. [PMID: 34420107 DOI: 10.1007/s00701-021-04962-5] [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: 05/24/2021] [Accepted: 07/31/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Petrous bone lesions (PBLs) are rare with few reports in the neurosurgical literature. In this study, the authors describe our current technique of extradural subtemporal approach (ESTA). The objective of this study was to evaluate the role and efficacy of ESTA for treatment of the PBLs. To our knowledge, this is the largest reported clinical series of using an ESTA-treated PBLs in which the clinical outcomes were evaluated. METHODS Between 1994 and 2019, 67 patients with PBLs treated by ESTA were retrospectively reviewed. Extent of resection, neurological outcomes, recurrence rate, and surgical complications were evaluated and compared with previous studies. The indications, advantages, limitations, and outcomes of ESTA were analyzed according to pathology. RESULTS This series included 7 facial nerve schwannomas (10.4%), 16 cholesterol granulomas (23.9%), 16 chordomas (23.9%), 6 chondrosarcomas (9%), 5 trigeminal schwannomas (7.5%), 9 epidermoids/dermoids (13.4%), and 8 other pathologies (11.9%). The most common location of PBLs operated with ESTA was at the petrous apex and rhomboid areas (68.7%). Gross total resection was achieved in 35 (55.6%). Symptomatic improvement occurred in 56 patients (83.6%). Complications occurred in 7 (10.4%) of cases including one mortality. Nine patients (17%) had recurrence within the mean follow-up 71 months. Compared to previous literature, our results demonstrated comparable outcomes but with higher rates of hearing and facial nerve preservation as well as minimal morbidity. From our results, ESTA is an effective therapeutic option for lesions located at the rhomboid and petrous apex, particularly when patients presented with intact facial and hearing function. CONCLUSION Our series demonstrated that ESTA provided satisfactory outcomes with excellent benefits of hearing and facial function preservation for patients with petrous bone lesions. ESTA should be considered as a safe and effective therapeutic option for selected patients with PBLs.
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Rennert RC, Brandel MG, Steinberg JA, Martin JR, Gonda DD, Fukushima T, Day JD, Khalessi AA, Levy ML. Surgical Relevance of Pediatric Anterior Clinoid Process Maturation for Anterior Skull Base Approaches. Oper Neurosurg (Hagerstown) 2021; 20:E200-E207. [PMID: 33372959 DOI: 10.1093/ons/opaa374] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/06/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Removal of the anterior clinoid process (ACP) can expand anterior skull base surgical corridors. ACP development and anatomical variations are poorly defined in children. OBJECTIVE To perform a morphometric analysis of the ACP during pediatric maturation. METHODS Measurements of ACP base thickness (ACP-BT), midpoint thickness (ACP-MT), length (ACP-L), length from optic strut to ACP tip (ACP-OS), pneumatization (ACP-pneumo), and the presence of an ossified carotico-clinoid ligament (OCCL) or interclinoid ligament (OIL) were made from high-resolution computed-tomography scans from 60 patients (ages 0-3, 4-7, 8-11 12-15, 16-18, and >18 yr). Data were analyzed by laterality, sex, and age groups using t-tests and linear regression. RESULTS There were no significant differences in ACP parameters by laterality or sex, and no significant growth in ACP-BT or ACP-MT during development. From ages 0-3 yr to adult, mean ACP-L increased 49%, from 7.7 to 11.5 mm. The majority of ACP-L growth occurred in 2 phases between ages 0-3 to 8-11 and ages 16-18 to adult. Conversely, ACP-OS was stable from ages 0-3 to 8-11 but increased by 63% between ages 8-11 to adult. Variations in ACP morphology (OCCL/OIL/ACP-pneumo) were found in 15% (9/60) of scans. OCCL and OIL occurred in patients as young as 3 yrs, whereas ACP-pneumo was not seen in patients younger than 11 yrs. CONCLUSION The ACP demonstrates stable thickness and a complex triphasic elongation and remodeling pattern with development, the understanding of which may facilitate removal in patients <12. Clinically relevant ACP anatomic variations can occur at any age.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Michael G Brandel
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Jeffrey A Steinberg
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Joel R Martin
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - David D Gonda
- Department of Neurosciences and Pediatrics, University of California, San Diego, San Diego, California
| | | | - John D Day
- Department of Neurosurgery, University of Arkansas, Little Rock, Arkansas
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California, San Diego, La Jolla, California
| | - Michael L Levy
- Department of Neurosciences and Pediatrics, University of California, San Diego, San Diego, California
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Rennert RC, Levy DM, Plonsker J, Steinberg JA, Friedman RA, Crawford JR, Levy ML. Middle fossa approach for a pediatric facial nerve meningioma. J Neurosurg Pediatr 2020; 26:578-582. [PMID: 32858509 DOI: 10.3171/2020.5.peds2034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 05/19/2020] [Indexed: 11/06/2022]
Abstract
Pediatric cerebellopontine angle (CPA) meningiomas are extremely rare and are usually treated with a retrosigmoid surgical approach or radiation. The authors present the use of a middle fossa approach for the treatment of a symptomatic CPA meningioma in a 22-month-old female. The patient initially presented at 17 months with isolated progressive, long-standing right-sided facial weakness. MRI demonstrated a 5.0 × 5.0-mm right CPA lesion just superior to the cisternal segment of cranial nerve (CN) VII, which demonstrated growth on interval imaging. At 22 months of age she underwent a successful middle fossa craniotomy, including wide exposure of the porus acusticus, allowing for a gross-total resection with preservation of CNs VII and VIII. Pathological analysis revealed a WHO grade I meningioma. The patient remained neurologically stable on follow-up. The middle fossa approach can be used to safely access the CPA in properly selected pediatric patients.
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Affiliation(s)
| | | | | | | | - Rick A Friedman
- 2Surgery, Division of Otolaryngology, Head and Neck Surgery, and
| | - John R Crawford
- 3Neurosciences and Pediatrics, University of California, San Diego, California
| | - Michael L Levy
- 3Neurosciences and Pediatrics, University of California, San Diego, California
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Cavalheiro S, Serrato-Avila JL, Párraga RG, Da Costa MDS, Nicácio JM, Rocha PR, Chaddad-Neto F. Interpeduncular Sulcus Approach to the Posterolateral Pons. World Neurosurg 2020; 138:e795-e805. [PMID: 32217179 DOI: 10.1016/j.wneu.2020.03.084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/15/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In this article, we describe a new safe entry point for the posterolateral pons. METHODS To show the adjacent anatomy and measure the part of the interpeduncular sulcus that can be safely accessed, we first performed a review of the literature regarding the pons anatomy and its surgical approaches. Thereafter, 1 human cadaveric head and 15 (30 sides) human brainstems with attached cerebellums were bilaterally dissected with the fiber microdissection technique. A clinical correlation was made with an illustrative case of a dorsolateral pontine World Health Organization grade I astrocytoma. RESULTS The safe distance for accessing the interpeduncular sulcus was found to extend from the caudal end of the lateral mesencephalic sulcus to the point at which the intrapontine segment of the trigeminal nerve crosses the interpeduncular sulcus. The mean distance was 8.2 mm (range, 7.15-8.85 mm). Our interpeduncular sulcus safe entry zone can be exposed through a paramedian infratentorial supracerebellar approach. When additional exposure is required, the superior portion of the quadrangular lobule of the cerebellar hemispheric tentorial surface can be removed. In the presented case, surgical resection of the tumor was performed achieving a gross total resection, and the patient was discharged without neurologic deficit. CONCLUSIONS The interpeduncular sulcus safe entry zone provides an alternative direct route for treating intrinsic pathologic entities situated in the posterolateral tegmen of the pons between the superior and middle cerebellar peduncles. The surgical corridor provided by this entry point avoids most eloquent neural structures, thereby preventing surgical complications.
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Affiliation(s)
- Sergio Cavalheiro
- Department of Neurosurgery, Pediatric Oncology Institute, Federal University of São Paulo, São Paulo, Brazil
| | | | - Richard Gonzalo Párraga
- Department of Neurosurgery, Neurosurgery Institute of Bolivia (INEB), Cochabamba, Bolivia; Department of Neurological Surgery, Hospital UNIVALLE, Cochabamba, Bolivia
| | - M D S Da Costa
- Department of Neurosurgery, Pediatric Oncology Institute, Federal University of São Paulo, São Paulo, Brazil
| | - Jardel Mendoça Nicácio
- Department of Neurosurgery, Pediatric Oncology Institute, Federal University of São Paulo, São Paulo, Brazil
| | - Paulo Ricardo Rocha
- Department of Morphology and Genetics, Federal University of São Paulo, São Paulo, Brazil
| | - Feres Chaddad-Neto
- Department of Neurosurgery, Vascular Division, Federal University of São Paulo, São Paulo, Brazil; Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
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Rennert RC, Hoshide R, Brandel MG, Steinberg JA, Martin JR, Meltzer HS, Gonda DD, Fukushima T, Khalessi AA, Levy ML. Surgical relevance of pediatric skull base maturation for the far-lateral and extreme-lateral infrajugular transcondylar-transtubercular exposure approaches. J Neurosurg Pediatr 2019; 24:85-91. [PMID: 31026824 DOI: 10.3171/2019.2.peds18621] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 02/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Lesions of the foramen magnum, inferolateral-to-midclival areas, and ventral pons and medulla are often treated using a far-lateral or extreme-lateral infrajugular transcondylar-transtubercular exposure (ELITE) approach. The development and surgical relevance of critical posterior skull base bony structures encountered during these approaches, including the occipital condyle (OC), hypoglossal canal (HGC), and jugular tubercle (JT), are nonetheless poorly defined in the pediatric population. METHODS Measurements from high-resolution CT scans were made of the relevant posterior skull base anatomy (HGC depth from posterior edge of the OC, OC and JT dimensions) from 60 patients (evenly distributed among ages 0-3, 4-7, 8-11, 12-15, 16-18, and > 18 years), and compared between laterality, sex, and age groups by using t-tests and linear regression. RESULTS There were no significant differences in posterior skull base parameters by laterality, and HGC depth and JT size did not differ by sex. The OC area was significantly larger in males versus females (174.3 vs 152.2 mm2; p = 0.01). From ages 0-3 years to adult, the mean HGC depth increased 27% (from 9.0 to 11.4 mm) and the OC area increased 52% (from 121.4 to 184.0 mm2). The majority of growth for these parameters occurred between the 0-3 year and 4-7 year age groups. Conversely, JT volume increased nearly 3-fold (281%) from 97.4 to 370.9 mm3 from ages 0-3 years to adult, with two periods of substantial growth seen between the 0-3 to 4-7 year and the 12-15 to 16-18 year age groups. Overall, JT growth during pediatric development was significantly greater than increases in HGC depth and OC area (p < 0.05). JT volume remained < 65% of adult size up to age 16. CONCLUSIONS When considering a far-lateral or ELITE approach in pediatric patients, standard OC drilling is likely to be needed due to the relative stability of OC and HGC anatomy during development. The JT significantly increases in size with development, yet is only likely to need to be drilled in older children (> 16 years) and adults.
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Affiliation(s)
- Robert C Rennert
- 1Department of Neurological Surgery, University of California San Diego, La Jolla
| | - Reid Hoshide
- 1Department of Neurological Surgery, University of California San Diego, La Jolla
| | - Michael G Brandel
- 1Department of Neurological Surgery, University of California San Diego, La Jolla
| | - Jeffrey A Steinberg
- 1Department of Neurological Surgery, University of California San Diego, La Jolla
| | - Joel R Martin
- 1Department of Neurological Surgery, University of California San Diego, La Jolla
| | - Hal S Meltzer
- 2Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, California; and
| | - David D Gonda
- 2Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, California; and
| | | | - Alexander A Khalessi
- 1Department of Neurological Surgery, University of California San Diego, La Jolla
| | - Michael L Levy
- 2Department of Neurosciences and Pediatrics, University of California San Diego, San Diego, California; and
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Comprehensive review of the extended middle cranial fossa approach. Curr Opin Otolaryngol Head Neck Surg 2018; 26:286-292. [PMID: 29957681 DOI: 10.1097/moo.0000000000000471] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review the current literature on the extended middle cranial fossa (xMCF) approach and to provide a comprehensive description of the relevant anatomy, indications, surgical technique, results, and complications. RECENT FINDINGS The xMCF approach expands the surgical exposure provided by the sMCF approach, allowing access to the internal auditory canal, cerebellopontine angle, prepontine cistern, anterior petrous apex, petrous carotid artery, Meckel's cave, cavernous sinus, mid and upper clivus, and posterior lesions approaching the jugular foramen. Preservation of serviceable hearing is possible with success rates approximating 50% in vestibular schwannoma and meningioma resection, and facial nerve outcome is excellent. SUMMARY The xMCF is an important approach for difficult to access lesions that additionally offers the possibility of hearing preservation. This approach is also useful for vascular lesions, auditory brainstem implantation, and lesions of mid-brainstem.
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