1
|
Liu J, Zhao J, Wang Y, Zhao Y, Han J, Yang D. Endoscopic endonasal transpterygoid nasopharyngectomy: Anatomical considerations and technical note. Head Neck 2024; 46:306-320. [PMID: 37987238 DOI: 10.1002/hed.27581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 10/01/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND The study was designed to identify new landmarks in the parapharyngeal segment of the internal carotid artery (ICA) for nasopharyngectomy and describe a surgical procedure of endoscopic endonasal transpterygoid nasopharyngectomy (EETPN). METHODS Four cadaveric specimens were injected with colored silicone and subjected to CT scanning before dissection. The nasopharyngeal skull base was exposed using the endoscopic endonasal transpterygoid approach. The clinical data of four patients with nasopharyngeal malignances who underwent EETPN were reviewed. RESULTS The lateral edge of the longus capitis muscle medially; the foramen lacerum, petrous apex spine and the stump of the levator veli palatini muscle superior laterally; and the upper parapharyngeal ICA laterally constitute the ICA-longus capitis muscle-petrous apex spine triangle which was a novel landmark for the upper parapharyngeal segment of the ICA. CONCLUSION The ICA-longus capitis muscle-petrous apex spine triangle are important landmarks of the upper parapharyngeal segment of the ICA.
Collapse
Affiliation(s)
- Jianfeng Liu
- Department of Otorhinolaryngology - Head & Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jianhui Zhao
- Department of Otorhinolaryngology - Head & Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Yibei Wang
- Department of Otorhinolaryngology - Head & Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Yu Zhao
- Department of Otorhinolaryngology - Head & Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jun Han
- Department of Otorhinolaryngology - Head & Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Dazhang Yang
- Department of Otorhinolaryngology - Head & Neck Surgery, China-Japan Friendship Hospital, Beijing, China
| |
Collapse
|
2
|
Özdemir A, Bayar Muluk N, Şencan Z. Is there a relationship between sphenoid sinus pneumatization and carotid canal-intersinus septa connection? Int J Neurosci 2024:1-8. [PMID: 38294684 DOI: 10.1080/00207454.2024.2313011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 01/27/2024] [Indexed: 02/01/2024]
Abstract
OBJECTIVES We investigated the relationship between sphenoid sinus (SS) pneumatization types, carotid canal types and carotid canal-intersinus septa connection. METHODS The paranasal sinus computed tomography (PNSCT) images of 274 patients (141 males and 133 females) were evaluated retrospectively. SS pneumatization, SS intersinus septation, SS intersinus septa deviation, carotid canal classification, carotid canal dehiscence, carotid canal-intersinus septa connection and presence of Onodi cells were evaluated. RESULTS In presellar and sellar SS, type 1 carotid canal was detected. However, type 3 carotid canal was detected more in postsellar SS. On the left side, in 26.4% of the postsellar SS, carotid canal dehiscence was detected. On the right side, carotid canal-intersinus septa connection was detected in 55.8% of the postsellar SS and 35.1% of the sellar SS. On the left side, it was detected 58.3% of the postsellar SS and 30.9% of the sellar SS. In postsellar type SS pneumatized cases, right caroid canal-intersinus septa connection increased by 5.4 fold and left carotid canal-intersinus septa connection increased by 7.3 fold compared to presellar type SS pneumatization. In 2≥ intersinus septa group, left carotid canal-intersinus septa connection increased 5.0 fold compared to 'no septa' group. CONCLUSION In this study, we evaluated SS pneumatization types and their relation with carotid canal types and carotid canal-intersinus septa connections. Type 3 carotid canal (protrudation to SS wall) was detected more in postsellar SS. In these cases, surgeons should be very careful during surgery to avoid damage to the internal carotid artery (ICA).
Collapse
Affiliation(s)
- Adnan Özdemir
- Faculty of Medicine, Radiology Department, Kırıkkale University, Kırıkkale, Turkey
| | - Nuray Bayar Muluk
- Faculty of Medicine, ENT Department, Kırıkkale University, Kırıkkale, Turkey
| | - Ziya Şencan
- Faculty of Medicine, ENT Department, Kırıkkale University, Kırıkkale, Turkey
| |
Collapse
|
3
|
Zhou C, Lei T, Sun J, Zhao H, Yu X, Cao W, Lv W, Zhang J. Endoscopic cadaveric analysis of the origin of the ophthalmic artery. Surg Radiol Anat 2023; 45:1435-1441. [PMID: 37594530 PMCID: PMC10587203 DOI: 10.1007/s00276-023-03234-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 08/10/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE The ophthalmic artery is often involved in suprasellar and parasellar surgeries, but the anatomical structure where the ophthalmic artery originates has not been fully clarified from the perspective of an endoscopic endonasal approach (EEA). METHODS A total of 10 fresh cadaveric heads (20 sides) were dissected through an EEA, and the origin of the bilateral ophthalmic arteries and their adjacent structures were observed from a ventral view. The origin of the ophthalmic artery in 50 healthy people was retrospectively studied on computed tomography angiography imaging. RESULTS The ophthalmic artery originated from the intradural segment (75%), paraclinoid segment (15%), or parasellar segment (10%) of the internal carotid artery. The cross-sectional view of the internal carotid artery through the EEA showed that the ophthalmic artery originated from the middle 1/3 (75%) or medial 1/3 (25%) of the upper surface of the internal carotid artery. On computed tomography angiography, the ophthalmic artery originated from the middle 1/3 (77%) and medial 1/3 (22%) of the upper surface of the internal carotid artery. All ophthalmic arteries were near the level of the distal dural ring (DDR) of the internal carotid artery, that is, within 3 mm above or below the DDR. CONCLUSIONS The ophthalmic artery usually originates in the middle 1/3 of the upper surface of the intradural segment of the internal carotid artery within 3 mm of the DDR. The ophthalmic artery can be protected to the utmost extent after its origin is identified through an EEA.
Collapse
Affiliation(s)
- Chunhui Zhou
- Department of Neurosurgery, Sixth Medical Center of PLA General Hospital, Beijing, People's Republic of China
| | - Ting Lei
- Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Junzhao Sun
- Department of Neurosurgery, Sixth Medical Center of PLA General Hospital, Beijing, People's Republic of China
| | - Hulin Zhao
- Department of Neurosurgery, Sixth Medical Center of PLA General Hospital, Beijing, People's Republic of China
| | - Xin Yu
- Department of Neurosurgery, Sixth Medical Center of PLA General Hospital, Beijing, People's Republic of China
| | - Weidong Cao
- Department of Neurosurgery, Sixth Medical Center of PLA General Hospital, Beijing, People's Republic of China
| | - Wenying Lv
- Department of Neurosurgery, Sixth Medical Center of PLA General Hospital, Beijing, People's Republic of China
| | - Jianning Zhang
- Department of Neurosurgery, Sixth Medical Center of PLA General Hospital, Beijing, People's Republic of China.
| |
Collapse
|
4
|
Bove I, Solari D. Endoscopic endonasal pituitary surgery: How we do it. Consensus statement on behalf of the EANS skull base section. Brain Spine 2023; 3:102687. [PMID: 38021006 PMCID: PMC10668107 DOI: 10.1016/j.bas.2023.102687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/25/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023]
Abstract
Introduction and research question The use of an endoscope in skull base surgery provides a panoramic close-up view over the intracranial structures from multiple angles with excellent illumination, thus permitting greater extent of resection of tumors arising at sellar area, mostly represented by PitNet - Pituitary neuroendocrine tumors, with higher likelihood of preserving vital/intact gland tissue. For this refined specialty of neurosurgery, unique skills need to be acquired along a steep learning curve. Material and methods EANS (European Association of Neurosurgical Societies) skull base section panelists were enrolled and 11 completed the survey: the goal was to provide a consensus statement of the endoscopic endonasal approach for pituitary adenoma surgery. Results The survey consisted of 44 questions covering demographics data (i.e., academic/non-academic center, case load, years of experience), surgical techniques (i.e., use of neuronavigation, preoperative imaging), and follow-up management. Discussion and conclusions In this paper we identified a series of tips and tricks at different phases of an endoscopic endonasal pituitary surgery procedure to underline the crucial steps to perform successful surgery and reduce complications: we took in consideration the principles of the surgical technique, the knowledge of the anatomy and its variations, and finally the importance of adjoining specialties experts.
Collapse
Affiliation(s)
- Ilaria Bove
- Department of Neurosurgery, University of Naples Federico II, Naples, Italy
| | - Domenico Solari
- Department of Neurosurgery, University of Naples Federico II, Naples, Italy
| |
Collapse
|
5
|
Cinalli MA, Malineni S, Spennato P, Nayak SS, Cinalli G, Deopujari C. Neuroendoscopy: intraventricular and skull base tumor resection in children. Childs Nerv Syst 2023; 39:2737-2756. [PMID: 37589762 DOI: 10.1007/s00381-023-06110-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 07/28/2023] [Indexed: 08/18/2023]
Abstract
During the last 30 years, the neurosurgeons have witnessed a revolution in the practice of interventricular surgery. The advent of neuroendoscopy at the end of the 1980s has allowed a minimally invasive management of a very large series of pathologies in pediatric neurosurgery ranging from hydrocephalus to arachnoid cyst to intraventricular tumors. The progresses in the management of hydrocephalus, intracranial cyst, and the fluid filled collection nevertheless has been more rapid and radical due to the simpler equipment that is necessary to perform this kind of surgery. The intraventricular tumors instead have been addressed in a slower way, and for many years, the only endoscopic procedure that was allowed on interventricular tumors was a biopsy associated with the management of hydrocephalus. Only very small tumors have been considered operable for complete removal during many years due to the limitations of the neuroendoscopic equipment and to the small calibers of the working channel. More recently, the advent of new devices and new surgical techniques are offering new perspectives on the possibility of intraventricular tumor surgery in children. In this review, we describe the historical perspective of the learning curve of intraventricular tumor surgery under neuroendoscopic control and try to offer a view of the future perspective in the removal of larger intraventricular tumors, analyzing the main indications for intraventricular endoscopic tumor surgery. We offer as well an historical perspective of the evolution of skull base surgery and endonasal transsphenoidal approach for skull-based tumors in children. This kind of surgery that has acquired widespread acceptance for many pathologies in adult age has diffused more slowly in pediatric neurosurgery due to the anatomical limitation observed in these age range. Also in this field, the slow evolution of the technique and of the technology available to neurosurgeons has allowed a very significant expansion of indication for the minimally invasive removal of skull base tumors in children.
Collapse
Affiliation(s)
| | - Suhas Malineni
- Department of Neurosurgery, Bombay Hospital, Mumbai, India
| | - Pietro Spennato
- Pediatric Neurosurgery Unit, Department of Pediatric Neurosciences, Santobono-Pausilipon Children's Hospital (AORN), Via Mario Fiore N. 6, 80129, Naples, Italy
| | | | - Giuseppe Cinalli
- Pediatric Neurosurgery Unit, Department of Pediatric Neurosciences, Santobono-Pausilipon Children's Hospital (AORN), Via Mario Fiore N. 6, 80129, Naples, Italy.
| | | |
Collapse
|
6
|
Corvino S, Armocida D, Offi M, Pennisi G, Burattini B, Mondragon AV, Esposito F, Cavallo LM, de Notaris M. The anterolateral triangle as window on the foramen lacerum from transorbital corridor: anatomical study and technical nuances. Acta Neurochir (Wien) 2023; 165:2407-2419. [PMID: 37479917 PMCID: PMC10477108 DOI: 10.1007/s00701-023-05704-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/25/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE Neurosurgical indications for the superior eyelid transorbital endoscopic approach (SETOA) are rapidly expanding over the last years. Nevertheless, as any new technique, a detailed knowledge of the anatomy of the surgical target area, the operative corridor, and the specific surgical landmark from this different perspective is required for a safest and successful surgery. Therefore, the aim of this study is to provide, through anatomical dissections, a detailed investigation of the surgical anatomy revealed by SETOA via anterolateral triangle of the middle cranial fossa. We also sought to define the relevant surgical landmarks of this operative corridor. METHODS Eight embalmed and injected adult cadaveric specimens (16 sides) underwent dissection and exposure of the cavernous sinus and middle cranial fossa via superior eyelid endoscopic transorbital approach. The anterolateral triangle was opened and its content exposed. An extended endoscopic endonasal trans-clival approach (EEEA) with exposure of the cavernous sinus content and skeletonization of the paraclival and parasellar segments of the internal carotid artery (ICA) was also performed, and the anterolateral triangle was exposed. Measurements of the surface area of this triangle from both surgical corridors were calculated in three head specimens using coordinates of its borders under image-guide navigation. RESULTS The drilling of the anterolateral triangle via SETOA unfolds a space that can be divided by the course of the vidian nerve into two windows, a wider "supravidian" and a narrower "infravidian," which reveal different anatomical corridors: a "medial supravidian" and a "lateral supravidian," divided by the lacerum segment of the ICA, leading to the lower clivus, and to the medial aspect of the Meckel's cave and terminal part of the horizontal petrous ICA, respectively. The infravidian corridor leads medially into the sphenoid sinus. The arithmetic means of the accessible surface area of the anterolateral triangle were 45.48 ± 3.31 and 42.32 ± 2.17 mm2 through transorbital approach and endonasal approach, respectively. CONCLUSION SETOA can be considered a minimally invasive route complementary to the extended endoscopic endonasal approach to the anteromedial aspect of the Meckel's cave and the foramen lacerum. The lateral loop of the trigeminal nerve represents a reliable surgical landmark to localize the lacerum segment of the ICA from this corridor. Nevertheless, as any new technique, a learning curve is needed, and the clinical feasibility should be proven.
Collapse
Affiliation(s)
- Sergio Corvino
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, 80131, Naples, Italy.
- PhD Program in Neuroscience, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, 80131, Naples, Italy.
| | - Daniele Armocida
- Neurosurgery Division, Human Neurosciences Department, "Sapienza" University, 00185, Rome, Italy
| | - Martina Offi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy - Division of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Giovanni Pennisi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy - Division of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Benedetta Burattini
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy - Division of Neurosurgery, Catholic University of Rome, Rome, Italy
| | | | - Felice Esposito
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, 80131, Naples, Italy
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, 80131, Naples, Italy
| | - Matteo de Notaris
- Department of Neuroscience, Neurosurgery Operative Unit, "San Pio" Hospital, 82100, Benevento, Italy
- Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy
| |
Collapse
|
7
|
Revuelta Barbero JM, Soriano RM, Porto E, Bray DP, Barrow E, Henriquez O, Solares CA, Pradilla G. Purely nasal floor mucosa-free graft for reconstruction after endoscopic endonasal transellar approach: an anatomical and clinical analysis. Br J Neurosurg 2023:1-6. [PMID: 37082915 DOI: 10.1080/02688697.2023.2202233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND/OBJECTIVE In this radioanatomical study with clinical correlate, we study a variation of the 'extended nasal floor mucosa' (ENFM) free-graft, the purely nasal floor mucosa (PuNFM) free-graft. The objectives of this study are to evaluate the coverage surface area provided by the PuNFM, study the adequacy of the PuNFM in the reconstruction of endoscopic endonasal approach (EEA) transsellar postoperative defects and compare and evaluate this reconstructive technique with current sellar region reconstruction practices. METHODS Dissections were performed on five cadaveric specimens. PuNFM were harvested bilaterally and the area provided for reconstruction was calculated. Twenty-five consecutive cases of pituitary adenomas resected through an EEA were analyzed to estimate the sellar defect surface area (SDSA) after a transsellar EEA and calculate the area of PuNFM bilaterally. RESULTS The median cadaveric SDSA was 4.77 cm2, with a median left and right side PuNFM area of 5.09 and 5.19 cm2, respectively. Clinically, the median SDSA was 5.36 cm2, and the total radiological PuNFM surface area was 5.46 cm2, with modified Knosp grade >2 tumors having larger SDSA than that of Knosp grade <2 tumors. The PuNFM graft proved to be most effective for covering modified Knosp <2 tumor defects. CONCLUSIONS The PuNFM represents a variation of the ENFM free-graft sellar defect reconstruction technique that provides sufficient surface area to reconstruct the majority of the sellar defects related to transsellar EAA for pituitary adenomas. This technique may positively impact sinonasal function and quality of life. Future prospective clinical studies are needed to verify these findings.
Collapse
Affiliation(s)
| | - Roberto M Soriano
- Department of Otolaryngology Head and Neck Surgery, Emory University, Atlanta, GA, USA
| | - Edoardo Porto
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - David P Bray
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - Emily Barrow
- Department of Otolaryngology Head and Neck Surgery, Emory University, Atlanta, GA, USA
| | - Oswaldo Henriquez
- Department of Otolaryngology Head and Neck Surgery, Emory University, Atlanta, GA, USA
| | - C Arturo Solares
- Department of Otolaryngology Head and Neck Surgery, Emory University, Atlanta, GA, USA
| | | |
Collapse
|
8
|
Connor SEJ, Thomas NWM, Shapey J. Localisation of the petrous internal carotid artery relative to the vidian canal on computed tomography: a case-control study evaluating the impact of petroclival chondrosarcoma. Acta Neurochir (Wien) 2022. [PMID: 35612666 DOI: 10.1007/s00701-022-05254-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/13/2022] [Indexed: 11/11/2022]
Abstract
Background The vidian canal (VC) is normally a reliable anatomical landmark for locating the petrous internal carotid artery (pICA). This study determined the influence of petroclival chondrosarcoma on the relationship between the VC and pICA. Methods Nine patients (3 males, 6 females; median age 49) with petroclival chondrosarcoma, and depiction of the pICA on contrast-enhanced CT, were retrospectively studied. CT-based measurements were performed by two observers, both in the presence of the petroclival chondrosarcoma (case) and on the contralateral control side. The antero-posterior (AP) and craniocaudal (CC) measurements from the posterior VC to the pICA, whether the pICA was in the trajectory of the VC, and the coronal relationship of the pICA anterior genu with the VC were recorded. Results Chondrosarcoma usually displaced the pICA anteriorly (8/9 cases) and superiorly (6/9 cases) relative to the normal side with mean AP and CC measurements of 3.9 mm v 7.2 mm (p = 0.054) and 4.4 mm v 1.4 mm (p = 0.061). The VC trajectory less frequently intersected the pICA cross-section in the presence of chondrosarcoma however it was in the line of the eroded dorsal VC in one case. The anterior genu of the pICA was displaced more laterally by chondrosarcoma but usually remained superior to the VC. Conclusion Petroclival chondrosarcoma variably influences the anatomical relationship between the VC and the pICA, hence requiring an individualised approach. The pICA is usually anterosuperiorly displaced, and the anterior genu remains superior to the VC, however it may be located in the line of the canal.
Collapse
|
9
|
Ismail M, Darwish M, Gomma M, Herzallah IR, El Tahan AER. Endoscopic Orientation of Juxta-Pituitary Carotid in Transsphenoidal Approaches: Critical Considerations for Clinical Applications. Indian J Otolaryngol Head Neck Surg 2021; 73:461-6. [PMID: 34692458 DOI: 10.1007/s12070-021-02454-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/08/2021] [Indexed: 10/22/2022] Open
Abstract
Accidental injury of the internal carotid artery (ICA) remains one of the most challenging complications reported in the endoscopic endonasal transsphenoidal approaches (EETA) particularly, in sphenoid sinuses with ill-defined carotid bony landmarks. The purpose of this study was to describe an anatomical model for the endoscopic orientation of juxta-pituitary segment of ICA in relation to the lateral optico-carotid recess (OCR) as a nearby bony landmark. Cadaveric dissection was conducted progressively in twenty fresh adult cadavers simulating the EETA. After reducing posterior and lateral walls of sphenoid sinuses, various measurements were taken from both lateral OCRs to "contact points" of the juxta-pituitary segment of ICA and lateral margins of the pituitary gland. Current results have enabled us to divide the region between lateral OCRs into three compartments. Two lateral parasellar compartments contain juxta-pituitary segments of ICA showing a mean width of 8 mm; with a narrow range of 7-10 mm; and a central inter-carotid sellar compartment represents the safe region for bone drilling showing widely variable widths ranging between 9 to 20 mm. In all specimens; variation in the width of the inter-carotid compartment correlated with the distance between both lateral OCRs. This study improves surgeons' awareness of the ICA course variations in the EETA through sphenoid sinuses with ill-defined bony landmarks. An appreciation of the measurements gathered from this study can help in operative training, and can also provide a base for future studies to confirm ICA courses associated with higher risk of injury.
Collapse
|
10
|
Jayashankar N, Patangrao H. Magnetic resonance angiographic study of variations in course of paraclival and parasellar internal carotid artery in relation to expanded endonasal endoscopic approaches. Eur Arch Otorhinolaryngol 2021. [PMID: 34652526 DOI: 10.1007/s00405-021-07123-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Abstract
AIMS To study the variations in the course of the paraclival and parasellar carotid arteries in normal subjects using magnetic resonance angiography as is relevant from an endoscopic endonasal perspective. METHODS Two hundred MR angiographies of normal subjects were analyzed in a prospective study. The intercarotid distances were measured at fixed points along the paraclival and parasellar segments of the internal carotid artery. The intercarotid spaces thus obtained were categorized into trapezoid, square and hourglass shapes. The angle between the posterior ascending vertical and horizontal bend of the parasellar ICA was also measured and analyzed. RESULTS The trapezoid shape of intercarotid space is the most common (52.5%), followed by the square (35%) and the hourglass (12.5%) shaped spaces. Angle of < 80° between the posterior ascending vertical and horizontal bend of the parasellar ICA was found in 39% of subjects, angle between 80° and 100° was found in 9% subjects, angle > 100° was found in 43% while asymmetric angles on the two sides was found in 9% of subjects. CONCLUSION A thorough understanding of the course of the ICA is important in planning the approach and preventing injury to the ICA.
Collapse
|
11
|
Zhao X, Labib MA, Avci E, Preul MC, Baskaya MK, Little AS, Nakaji P. Navigating a Carotico-Clinoid Foramen and an Interclinoidal Bridge in the Endonasal Endoscopic Approach: An Anatomical and Technical Note. J Neurol Surg B Skull Base 2021; 82:534-539. [PMID: 34513559 DOI: 10.1055/s-0040-1715470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/05/2020] [Indexed: 10/23/2022] Open
Abstract
Objective The carotico-clinoid foramen and interclinoid bridge are two anatomical variants of the sellar region. If these anatomical variants go unrecognized and are not managed safely by the surgeon during expanded endoscopic endonasal surgery for a posterior clinoidectomy, a carotid artery injury may occur. We summarize a method to safely navigate in the presence of the carotico-clinoid foramen and interclinoid bridge in an endoscopic endonasal approach. Study Design The study involves cadaveric dissection and management of the anatomical variants. Setting The study took place in a cadaveric dissection laboratory. Participants The object of study is one cadaveric head. Main Outcome Measures After discovering the two variants in both cavernous sinuses of a cadaveric head, we established a stepwise coping strategy to avoid carotid artery injury while performing an endoscopic endonasal bilateral interdural pituitary transposition, and we report the final view after endoscopic management. Results Debulking of the middle clinoid process can decrease the obstacle effect, and the pituitary transposition can be performed medial to the ossified carotico-clinoid ligament. Disconnection of the interclinoid bridge is the prerequisite to an effective posterior clinoidectomy, and distinguishing the transition between the sellar diaphragm and the interclinoid bridge is essential. Conclusion In the presence of both the carotico-clinoid foramen and the interclinoid bridge, a bilateral interdural pituitary transposition can still be performed, although preoperative strategic preparation, full inspection, and stepwise disconnections are of paramount importance in such a scenario to avoid cavernous carotid artery injury.
Collapse
Affiliation(s)
- Xiaochun Zhao
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Emel Avci
- Department of Neurosurgery, Mersin University, School of Medicine, Mersin, Turkey
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Mustafa K Baskaya
- Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin, United States
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| |
Collapse
|
12
|
Ferrari M, Cazzador D, Taboni S, Trimarchi MV, Emanuelli E, Nicolai P. When is a multidisciplinary surgical approach required in sinonasal tumours with cranial involvement? ACTA ACUST UNITED AC 2021; 41:S3-S17. [PMID: 34060516 PMCID: PMC8172110 DOI: 10.14639/0392-100x-suppl.1-41-2021-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/15/2021] [Indexed: 11/23/2022]
Abstract
The term “sinonasal tumours” includes a large spectrum of diseases, which are characterized by heterogeneous biological behavior and prognosis, and located in a critical anatomic area. Diagnosis and treatment of sinonasal tumours require the contribution of different disciplines. A narrative review was performed to highlight the role of surgeons in contributing to a multidisciplinary approach to sinonasal tumours. Diagnosis and staging of sinonasal tumours is challenging and requires collaboration between surgeons, radiologists, and pathologists. The identification and management of critical extensions (orbital or intracranial encroachment, vascular abutment or encasement) is fundamental for successful treatment. Most cases of advanced sinonasal tumours can undergo surgical intervention by an adequately trained otorhinolaryngological team. The contribution of neurosurgeons and oculoplastic surgeons is required in selected scenarios. In rare circumstances, multidisciplinary reconstructive strategies can be indicated for complex tissue defects. Furthermore, a multidisciplinary approach is pivotal in the management of perioperative complications. While surgery remains the mainstay of treatment, the role of non-surgical adjuvant or even exclusive treatments is constantly expanding.
Collapse
Affiliation(s)
- Marco Ferrari
- Section of Otorhinolaryngology, Head and Neck Surgery, University of Padua, "Azienda Ospedaliera di Padova", Padua, Italy.,Technology for Health (PhD program), Department of Information Engineering, University of Brescia, Brescia, Italy.,University Health Network (UHN) Guided Therapeutics (GTx) Program International Scholar, UHN, Toronto, Canada
| | - Diego Cazzador
- Section of Otorhinolaryngology, Head and Neck Surgery, University of Padua, "Azienda Ospedaliera di Padova", Padua, Italy
| | - Stefano Taboni
- Section of Otorhinolaryngology, Head and Neck Surgery, University of Padua, "Azienda Ospedaliera di Padova", Padua, Italy.,University Health Network (UHN) Guided Therapeutics (GTx) Program International Scholar, UHN, Toronto, Canada.,Artificial Intelligence in Medicine and Innovation in Clinical Research and Methodology (PhD program), Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Maria Vittoria Trimarchi
- Section of Otorhinolaryngology, Head and Neck Surgery, University of Padua, "Azienda Ospedaliera di Padova", Padua, Italy
| | - Enzo Emanuelli
- Section of Otorhinolaryngology, Head and Neck Surgery, University of Padua, "Azienda Ospedaliera di Padova", Padua, Italy
| | - Piero Nicolai
- Section of Otorhinolaryngology, Head and Neck Surgery, University of Padua, "Azienda Ospedaliera di Padova", Padua, Italy
| |
Collapse
|
13
|
London NR, AlQahtani A, Barbosa S, Castelnuovo P, Locatelli D, Stamm A, Cohen‐Gadol AA, Elbosraty H, Casiano R, Morcos J, Pasquini E, Frank G, Mazzatenta D, Barkhoudarian G, Griffiths C, Kelly D, Georgalas C, Janakiram TN, Nicolai P, Prevedello DM, Carrau RL. Characterization of outcomes and practices utilized in the management of internal carotid artery injury not requiring definitive endovascular management. Laryngoscope Investig Otolaryngol 2021; 6:634-640. [PMID: 34401483 PMCID: PMC8356855 DOI: 10.1002/lio2.621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/27/2021] [Accepted: 07/03/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND After internal carotid artery (ICA) injury during endoscopic skull base surgery, the majority of patients undergo ICA embolization or stenting to treat active extravasation or pseudoaneurysm development. However, management practices when embolization or stenting is not required have not been well described. The objective of this study was to determine how patients with ICA injury but no embolization, stenting, or ligation do long-term and ascertain the reconstruction methods utilized. METHODS Twenty-nine cases of ICA injury were identified in an international multi-institutional retrospective review. Of these, we identified six cases that were not treated with embolization, stenting, or ICA sacrifice. Information was available for five cases. RESULTS A muscle patch was used in the immediate repair of each case. A nasoseptal flap was used in one case. Prefabricated nasal tampons were used in all cases. Nasal packing was initially left in for a median of 7 days prior to removal. The initial muscle patch was reinforced with a second muscle graft in one case. One case demonstrated ICA bleeding at the time of packing removal and was repacked an additional week. Follow-up for each of these cases was at least 2 years. No cases of subsequent carotid rupture were found and none of these cases ultimately underwent endovascular stenting. Radiation or proton therapy has not been subsequently used in any of these patients. CONCLUSIONS This study details the reconstruction, lessons learned, and long-term follow-up for five cases of ICA injury not treated with embolization, stenting, or ligation.
Collapse
Affiliation(s)
- Nyall R. London
- Sinonasal and Skull Base Tumor Program, Head and Neck Surgery BranchNational Institute on Deafness and Other Communication Disorders, National Institutes of HealthBethesdaMarylandUSA
- Department of Otolaryngology – Head & Neck SurgeryJohns Hopkins MedicineBaltimoreMarylandUSA
- Department of Otolaryngology – Head & Neck SurgeryWexner Medical Center at The Ohio State UniversityColumbusOhioUSA
| | - Abdulaziz AlQahtani
- Department of Otorhinolaryngology – Head & Neck SurgeryKing Fahad Medical CityRiyadhSaudi Arabia
| | - Siani Barbosa
- Sinonasal and Skull Base Tumor Program, Head and Neck Surgery BranchNational Institute on Deafness and Other Communication Disorders, National Institutes of HealthBethesdaMarylandUSA
| | - Paolo Castelnuovo
- Division of Otorhinolaryngology, Department of Biotechnology and Life SciencesUniversity of InsubriaVareseItaly
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life SciencesUniversity of InsubriaVareseItaly
| | - Aldo Stamm
- Complexo Hospitalar Edmundo VasconcelosCentro de Otorrinolaringologia e Fonoaudiologia (COF)São PauloSão PauloBrazil
| | - Aaron A. Cohen‐Gadol
- Indiana University, Department of Neurosurgery and Goodman Campbell Brain and SpineIndianapolisIndianaUSA
| | - Hussam Elbosraty
- Department of Otorhinolaryngology, Faculty of MedicineCairo UniversityGizaEgypt
| | - Roy Casiano
- Department of Otolaryngology, Head & Neck SurgeryUniversity of Miami, Miller School of MedicineMiamiFloridaUSA
| | - Jacques Morcos
- Department of NeurosurgeryUniversity of MiamiMiamiFloridaUSA
| | | | - Georgio Frank
- Center of Pituitary and Endoscopic Skull Base SurgeryIstituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Diego Mazzatenta
- Center of Pituitary and Endoscopic Skull Base SurgeryIstituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Garni Barkhoudarian
- Pacific Brain Tumor Center and Pituitary Disorders ProgramJohn Wayne Cancer Institute at Providence Saint John's Health CenterSanta MonicaCaliforniaUSA
| | - Chester Griffiths
- Pacific Brain Tumor Center and Pituitary Disorders ProgramJohn Wayne Cancer Institute at Providence Saint John's Health CenterSanta MonicaCaliforniaUSA
| | - Daniel Kelly
- Pacific Brain Tumor Center and Pituitary Disorders ProgramJohn Wayne Cancer Institute at Providence Saint John's Health CenterSanta MonicaCaliforniaUSA
| | - Christos Georgalas
- Medical School, University of NicosiaCyprus and Hygeia HospitalAthensGreece
| | - Trichy N. Janakiram
- Department of Otorhinolaryngology, Royal Pearl HospitalTiruchirapallyTamil NaduIndia
| | - Piero Nicolai
- Unit of Otorhinolaryngology – Head and Neck Surgery, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Daniel M. Prevedello
- Department of Otolaryngology – Head & Neck SurgeryWexner Medical Center at The Ohio State UniversityColumbusOhioUSA
- Department of Neurosurgery, Wexner Medical CenterThe Ohio State UniversityColumbusOhioUSA
| | - Ricardo L. Carrau
- Department of Otolaryngology – Head & Neck SurgeryWexner Medical Center at The Ohio State UniversityColumbusOhioUSA
- Department of Neurosurgery, Wexner Medical CenterThe Ohio State UniversityColumbusOhioUSA
| |
Collapse
|
14
|
Karadag A, Kirgiz PG, Bozkurt B, Kucukyuruk B, ReFaey K, Middlebrooks EH, Senoglu M, Tanriover N. The benefits of inferolateral transtubercular route on intradural surgical exposure using the endoscopic endonasal transclival approach. Acta Neurochir (Wien) 2021; 163:2141-2154. [PMID: 33847826 DOI: 10.1007/s00701-021-04835-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/26/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical access to the ventral pontomedullary junction (PMJ) can be achieved through various corridors depending on the location and extension of the lesion. The jugular tubercle (JT), a surgically challenging obstacle to access the PMJ, typically needs to be addressed in transcranial exposures. We describe the endoscopic endonasal transclival approach (EETCA) and its inferolateral transtubercular extension to assess the intradural surgical field gained through JT removal. We also complement the dissections with an illustrative case. METHODS EETCA was surgically simulated, and the anatomical landmarks were assessed in eight cadaveric heads. Microsurgical dissections were additionally performed along the endoscopic surgical path. Lastly, we present an intraoperative video of the trans-JT approach in a patient with lower clival chordoma. RESULTS The EETCA allowed adequate extracranial visualization and removal of the JT. The surgical bony window-obtained along the clivus and centered at the JT via the EETCA-measured 11 × 9 × 7 mm. Removal of the JT provided an improved intradural field within the lower third of the cerebellopontine cistern to expose an area bordered by the cranial nerves VII/VIII and flocculus superior and anterior margin of the lateral recess of the fourth ventricle and cranial nerves IX-XI inferiorly, centered on the foramen of Luschka. CONCLUSIONS Removal of the JT via EETCA improves exposure along the lower third of the cerebellopontine and upper cerebellomedullary cisterns. The inferolateral transtubercular extension of the EETCA provides access to the lateral recess of the fourth ventricle, in combination with the ventral midline pontomedullary region.
Collapse
|
15
|
Xiao L, Xie S, Tang B, Wu X, Ding H, Bao Y, Hong T. A novel technique to manage internal carotid artery injury in endoscopic endonasal skull base surgery in the premise of proximal and distal controls. Neurosurg Rev 2021. [PMID: 33738637 DOI: 10.1007/s10143-021-01517-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/23/2021] [Accepted: 03/01/2021] [Indexed: 10/21/2022]
Abstract
Intraoperative internal carotid artery injury is one of the most daunting complications in endoscopic skull base surgery. This paper proposed a novel technique to manage ICA injury after proximal and distal controls. The appropriate block sites together with the proximal and distal controls of ICA were demonstrated in six injected cadaveric specimens. The surgical outcomes of five patients with intraoperative ICA injury and managed with this concept were retrospectively reviewed. Five block sites for vascular control could be identified in all six specimens, including (1) distal to the distal dural ring, (2) proximal to the proximal dural ring, (3) anterior genu of the parasellar ICA, (4) the upper third of the paraclival ICA, and (5) just above the foramen lacerum. Both proximal and distal controls of ICA were achieved by using the block sites in combination. Gross tumor resection was achieved in all five cases after the intraoperative ICA injury was successfully managed. Three coping techniques were used, including direct coagulation to seal (three cases), endoscopic suture (one case), and coagulation to sacrifice (one case). Focal brainstem infarction occurred in one case, one patient died of intracranial infection, and the other three cases had no sequelae. No pseudoaneurysm occurred in all patients. Except the sacrificed ICA, the other ICA was intact during follow-up. It is technically feasible to manage ICA injuries after proximal and distal controls during EEA surgeries. The surgical outcomes from our case series supported the use of this novel technique.
Collapse
|
16
|
Bafaquh M, Khairy S, Alyamany M, Alobaid A, Alzhrani G, Alkhaibary A, Aldhafeeri WF, Alaman AA, Aljohani HN, Elahi BN, Alghabban FA, Orz Y, Alturki AY. Classification of internal carotid artery injuries during endoscopic endonasal approaches to the skull base. Surg Neurol Int 2020; 11:357. [PMID: 33194290 PMCID: PMC7656006 DOI: 10.25259/sni_188_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/20/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Internal carotid artery (ICA) injuries are a major complication of endoscopic endonasal approaches (EEAs), which can be difficult to manage. Adding to the management difficulty is the lack of literature describing the surgical anatomical classification of these types of injuries. This article proposing a novel classification of ICA injuries during EEAs. Methods: The classification of ICA injuries during EEAs was generated from the review of the literature and analysis of the main author observation of ICA injuries in general. All published cases of ICA injuries during EEAs in the literature between January 1990 and January 2020 were carefully reviewed. We reviewed all patients’ demographic features, preoperative diagnoses, modes of injury, cerebral angiography results, surgical and medical management techniques, and reported functional outcomes. Results: There were 31 papers that reported ICA injuries during EEAs in the past three decades, most studies did not document the type of injury, and few described major laceration type of it. From that review of the literature, we classified ICA injuries into three main categories (Types I-III) and six sub-types. Type I is ICA branch injury, Type II is a penetrating injury to the ICA, and Type III is a laceration of the ICA wall. The functional neurological outcome was found to be worse with Type III and better with Type I. Conclusion: This is a novel classification system for ICA injuries during EEAs; it defines the patterns of injury. It could potentially lead to advancements in the management of ICA injuries in EEAs and facilitate communication to develop guidelines.
Collapse
Affiliation(s)
- Mohammed Bafaquh
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| | - Sami Khairy
- Division of Neurosurgery, Department of Surgery, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mahmoud Alyamany
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| | - Abdullah Alobaid
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| | - Gmaan Alzhrani
- Division of Neurosurgery, Department of Surgery, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ali Alkhaibary
- Division of Neurosurgery, Department of Surgery, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Wafa F Aldhafeeri
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| | - Areej A Alaman
- Division of Neurosurgery, Department of Surgery, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hanan N Aljohani
- Department of Neurosciences, Division of Neurosurgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Basim Noor Elahi
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| | - Fatimah A Alghabban
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| | - Yasser Orz
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman Y Alturki
- Department of Adult Neurosurgery, National Neuroscience Institute, King Fahed Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
17
|
Lin BJ, Ju DT, Wu YC, Kao HW, Tseng KY, Chung TT, Liu WH, Hueng DY, Chen YH, Hsia CC, Ma HI, Liu MY, Tang CT. Endoscopic transcanal transpetrosal approach to the petroclival region: a cadaveric study with comparison to the Kawase approach. Neurosurg Rev 2021; 44:2171-9. [PMID: 32936389 DOI: 10.1007/s10143-020-01389-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/26/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022]
Abstract
This study introduces expanded application of the endoscopic transcanal approach with anterior petrosectomy (ETAP) in reaching the petroclival region, which was compared through a quantitative analysis to the middle fossa transpetrosal-transtentorial approach (Kawase approach). Anatomical dissections were performed in five cadaveric heads. For each head, the ETAP was performed on one side with a detailed description of each step, while the Kawase approach was performed on the contralateral side. Quantitative measurements of the exposed area over the ventrolateral surface of the brainstem, and of the angles of attack to the posterior margin of the trigeminal nerve root entry zone (CN V-REZ) and porus acusticus internus (PAI) were obtained for statistical comparison. The ETAP provided significantly larger exposure over the ventrolateral surface of the pons (93.03 ± 21.87 mm2) than did the Kawase approach (34.57 ± 11.78 mm2). In contrast to the ETAP, the Kawase approach afforded greater angles of attack to the CN V-REZ and PAI in the vertical and horizontal planes. The ETAP is a feasible and minimally invasive procedure for accessing the petroclival region. In comparison to the Kawase approach, the ETAP allows for fully anterior petrosectomy and larger exposure over the ventrolateral surface of the brainstem without passing through the cranial nerves or requiring traction of the temporal lobe.
Collapse
|
18
|
Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Xu X, Ong YK. An endoscopic anatomical study of the levator veli palatini and its relationship to the parapharyngeal internal carotid artery. Head Neck 2020; 42:1829-1836. [PMID: 32043685 DOI: 10.1002/hed.26101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/30/2019] [Accepted: 01/28/2020] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The objectives of this study are to describe the levator veli palatini (LVP) as a landmark for the parapharyngeal internal carotid artery (pICA) and the endoscopic course of the pICA. METHODS Cadaver dissection and illustrative case study. RESULTS Seven cadaveric heads (12 sides) were dissected. In all 12 sides, the LVP was consistently located between the Eustachian tube and the pICA near the skull base, making the LVP just anterior to and the closest structure to the pICA. The distance between the pICA and the nares ranged from 9.0 to 12.7 cm. The distance between the pICA and the midpoint of the nasopharynx ranged from 1.9 to 3.7 cm. The case study illustrated the applicability of these findings. CONCLUSION The LVP is a reliable and precise landmark for the pICA. A safe working distance to the pICA is 1.9 cm from the midpoint of the nasopharynx and 9.0 cm from the nares.
Collapse
Affiliation(s)
- Xinni Xu
- Department of Otolaryngology - Head & Neck Surgery, National University Hospital, Singapore
| | - Yew Kwang Ong
- Department of Otolaryngology - Head & Neck Surgery, National University Hospital, Singapore
| |
Collapse
|
20
|
Tayebi Meybodi A, Borba Moreira L, Little AS, Lawton MT, Preul MC. Anatomical assessment of the endoscopic endonasal approach for the treatment of paraclinoid aneurysms. J Neurosurg 2019; 131:1734-1742. [DOI: 10.3171/2018.6.jns18800] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 06/27/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEEndoscopic endonasal approaches (EEAs) are increasingly being incorporated into the neurosurgeon’s armamentarium for treatment of various pathologies, including paraclinoid aneurysms. However, few anatomical assessments have been performed on the use of EEA for this purpose. The aim of the present study was to provide a comprehensive anatomical assessment of the EEA for the treatment of paraclinoid aneurysms.METHODSFive cadaveric heads underwent an endonasal transplanum-transtuberculum approach to expose the paraclinoid area. The feasibility of obtaining proximal and distal internal carotid artery (ICA) control as well as the topographic location of the origin of the ophthalmic artery (OphA) relative to dural landmarks were assessed. Limitations of the EEA in exposing the supraclinoid ICA were also recorded to identify favorable paraclinoid ICA aneurysm projections for EEA.RESULTSThe extracavernous paraclival and clinoidal ICAs were favorable segments for establishing proximal control. Clipping the extracavernous ICA risked injury to the trigeminal and abducens nerves, whereas clipping the clinoidal segment put the oculomotor nerve at risk. The OphA origin was found within 4 mm of the medial opticocarotid point on a line connecting the midtubercular recess point to the medial vertex of the lateral opticocarotid recess. An average 7.2-mm length of the supraclinoid ICA could be safely clipped for distal control. Assessments showed that small superiorly or medially projecting aneurysms were favorable candidates for clipping via EEA.CONCLUSIONSWhen used for paraclinoid aneurysms, the EEA carries certain risks to adjacent neurovascular structures during proximal control, dural opening, and distal control. While some authors have promoted this approach as feasible, this work demonstrates that it has significant limitations and may only be appropriate in highly selected cases that are not amenable to coiling or clipping. Further clinical experience with this approach helps to delineate its risks and benefits.
Collapse
|
21
|
Lin BJ, Ju DT, Hsu TH, Chung TT, Liu WH, Hueng DY, Chen YH, Hsia CC, Ma HI, Liu MY, Hung HC, Tang CT. Endoscopic transorbital approach to anterolateral skull base through inferior orbital fissure: a cadaveric study. Acta Neurochir (Wien) 2019; 161:1919-1929. [PMID: 31256277 DOI: 10.1007/s00701-019-03993-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Endoscopic transorbital approach (eTOA) has been announced as an alternative minimally invasive surgery to skull base. Owing to the inferior orbital fissure (IOF) connecting the orbit with surrounding pterygopalatine fossa (PPF), infratemporal fossa (ITF), and temporal fossa, the idea of eTOA to anterolateral skull base through IOF is postulated. The aim of this study is to access its practical feasibility. METHODS Anatomical dissections were performed in five human cadaveric heads (10 sides) using 0-degree and 30-degree endoscopes. A stepwise description of eTOA to anterolateral skull base through IOF was documented. The anterosuperior corner of the maxillary sinus in the horizontal plane of the upper edge of zygomatic arch was defined as reference point (RP). The distances between the RP to the foramen rotundum (FR), foramen ovale (FO), and Gasserian ganglion (GG) were measured. The exposed area of anterolateral skull base in the coronal plane of the posterior wall of the maxillary sinus was quantified. RESULTS The surgical procedure consisted of six steps: (1) lateral canthotomy with cantholysis and preseptal lower eyelid approach with periorbita dissection; (2) drilling of the ocular surface of greater sphenoid wing and lateral orbital rim osteotomy; (3) entry into the maxillary sinus and exposure of PPF and ITF; (4) mobilization of infraorbital nerve with drilling of the infratemporal surface of the greater sphenoid wing and pterygoid process; (5) exposure of middle cranial fossa, Meckel's cave, and lateral wall of cavernous sinus; and (6) reconstruction of orbital floor and lateral orbital rim. The distances measured were as follows: RP-FR = 45.0 ± 1.9 mm, RP-FO = 55.7 ± 0.5 mm, and RP-GG = 61.0 ± 1.6 mm. In comparison with the horizontal portion of greater sphenoid wing, the superior and inferior axes of the exposed area were 22.3 ± 2.1 mm and 20.5 ± 1.8 mm, respectively. With reference to the FR, the medial and lateral axes of the exposed area were 11.6 ± 1.1 mm and 15.8 ± 1.6 mm, respectively. CONCLUSIONS The eTOA through IOF can be used as a minimally invasive surgery to access whole anterolateral skull base. It provides a possible resolution to target lesion involving multiple compartments of anterolateral skull base.
Collapse
|
22
|
Li W, Chae R, Rubio RR, Benet A, Meybodi AT, Feng X, Huang G, El-Sayed IH. Characterization of Anatomical Landmarks for Exposing the Internal Carotid Artery in the Infratemporal Fossa Through an Endoscopic Transmasticator Approach: A Morphometric Cadaveric Study. World Neurosurg 2019; 131:e415-e424. [PMID: 31376554 DOI: 10.1016/j.wneu.2019.07.185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Eustachian tube and sphenoid spine have been previously described as landmarks for endonasal surgical identification of the most distal segment of the parapharyngeal internal carotid artery (PhICA). However, the intervening space between the sphenoid spine and PhICA allows for error during exposure of the artery. In the present study, we have characterized endoscopic endonasal transmasticator exposure of the PhICA using the sphenoid spine, vaginal process of the tympanic bone, and the "tympanic crest" as useful anatomical landmarks. METHODS Endonasal dissection was performed in 13 embalmed latex-injected cadaveric specimens. Two open lateral dissections and osteologic analysis of 10 dry skulls were also performed. RESULTS A novel and palpable bony landmark, the inferomedial edge of the tympanic bone, referred to as the tympanic crest, was identified, leading from the sphenoid spine to the lateral carotid canal. Additionally, the vaginal process of the tympanic bone, viewed endoscopically, was a guide to the PhICA. The sphenoid spine was bifurcate in 20% of the skulls, with an average length of 5.98 mm (range, 3.9-8.2 mm), width of 5.81 mm (range, 3.0-10.6 mm), and distance to the carotid canal of 4.48 mm (range, 2.5-6.1 mm). CONCLUSION The sphenoid spine and pericarotid space has variable anatomy. Using an endoscopic transmasticator approach to the infratemporal fossa, we found that the closest landmarks leading to the PhICA were the tympanic crest, sphenoid spine, and vaginal process of the tympanic bone.
Collapse
Affiliation(s)
- Wei Li
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA; Department of Otolaryngology-Head and Neck Surgery, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Ricky Chae
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA
| | - Roberto Rodriguez Rubio
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA; Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA
| | - Arnau Benet
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ali Tayebi Meybodi
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA; Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Xuequan Feng
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA; Department of Neurosurgery, Tianjin First Center Hospital, Nankai District, Tianjin, China
| | - Guanglong Huang
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA
| | - Ivan H El-Sayed
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, California, USA.
| |
Collapse
|
23
|
Revuelta Barbero JM, Noiphithak R, Yanez-siller JC, Subramaniam S, Calha MS, Otto BA, Carrau RL, Prevedello DM. Expanded Endoscopic Endonasal Approach to the Inframeatal Area: Anatomic Nuances with Surgical Implications. World Neurosurg 2018; 120:e1234-44. [DOI: 10.1016/j.wneu.2018.09.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 11/21/2022]
|
24
|
Beer-Furlan A, Servián DA, Carrau RL, Prevedello DM. Letter to the Editor. The triangulation technique for localizing the lacerum ICA in endoscopic endonasal skull base surgery. J Neurosurg 2018; 130:1-3. [PMID: 30485182 DOI: 10.3171/2018.8.jns182470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Diego A Servián
- Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH
| | - Ricardo L Carrau
- Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH
| | - Daniel M Prevedello
- Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH
| |
Collapse
|
25
|
Yeung W, Twigg V, Carr S, Sinha S, Mirza S. Radiological "Teddy Bear" Sign on CT Imaging to Aid Internal Carotid Artery Localization in Transsphenoidal Pituitary and Anterior Skull Base Surgery. J Neurol Surg B Skull Base 2018; 79:401-406. [PMID: 30009122 PMCID: PMC6043166 DOI: 10.1055/s-0037-1615749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 11/19/2017] [Indexed: 10/18/2022] Open
Abstract
Objectives Internal carotid artery (ICA) injury remains a rare but potentially fatal complication of transsphenoidal pituitary or anterior skull base surgery. Preoperative imaging must be scrutinized to minimize risk. On axial computed tomography (CT), the protrusions of the ICAs into the sphenoid resemble a "teddy bear." This article aims to describe the sign, its grading system (0-2) and quantify its presence. Design Retrospective review of preoperative CT imaging. Setting Tertiary referral center in the United Kingdom. Participants One hundred patients who underwent endoscopic transsphenoidal surgery for pituitary disease were enrolled. Main Outcome Measure The presence and grading of the "teddy bear" sign were assessed on preoperative CT imaging. Results A grade 2 (strongly positive) "teddy bear" sign was identified in 40% at the level of the superior pituitary fossa, 78% at the inferior pituitary fossa, and 59% at the clivus. A grade 1 (intermediate) sign was seen in 23.5, 7.5, and 10% of cases, respectively. In 5% of cases, the sign was grade 0 at all levels-indicating poor intraoperative localization of the ICA. Conclusion The "teddy bear" sign is a useful preoperative tool for identification of anatomy predisposing patients to a higher risk of ICA injury. Those patients who have an absent or grade 0 "teddy bear" sign require extra care to ensure intraoperative localization of the ICAs which may include the use of neuronavigation or a Doppler probe. A grade 2 sign predicts good intraoperative localization of the ICA intraoperatively to inform the safe lateral limit of sellar bone resection.
Collapse
Affiliation(s)
- W. Yeung
- Department of Otorhinolaryngology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - V. Twigg
- Department of Otorhinolaryngology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - S. Carr
- Department of Otorhinolaryngology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - S. Sinha
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - S. Mirza
- Department of Otorhinolaryngology, Royal Hallamshire Hospital, Sheffield, United Kingdom
| |
Collapse
|
26
|
Melé MV, Puigdellívol-Sánchez A, Mavar-Haramija M, Juanes-Méndez JA, Román LS, De Notaris M, Catapano G, Prats-Galino A. Review of the main surgical and angiographic-oriented classifications of the course of the internal carotid artery through a novel interactive 3D model. Neurosurg Rev 2020; 43:473-82. [PMID: 30051302 DOI: 10.1007/s10143-018-1012-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/31/2018] [Accepted: 07/10/2018] [Indexed: 12/24/2022]
Abstract
The course of the internal carotid artery (ICA) and its segment classifications were reviewed by means of a new and freely available 3D interactive model of the artery and the skull base, based on human neuroimages, that can be freely downloaded at the Public Repository of the University of Barcelona (http://diposit.ub.edu/dspace/handle/2445/112442) and runs under Acrobat Reader in Mac and Windows computers and Windows 10 tablets. The 3D-PDF allows zoom, rotation, selective visualization of structures, and a predefined sequence view. Illustrative images of the different classifications were obtained. Fischer (Zentralbl Neurochir 3:300-313, 1938) described five segments in the opposite direction to the blood flow. Gibo-Rothon (J Neurosurg 55:560-574, 1981) follow the blood flow, incorporated the cervical and petrous portions, and divided the subarachnoid course-supraclinoid-in ophthalmic, communicating, and choroidal segments, enhancing transcranial microscopic approaches. Bouthillier (Neurosurgery 38:425-433, 1996) divided the petrous portion describing the lacerum segment (exposed in transfacial procedures and exploration of Meckel's cave) and added the clinoid segment between the proximal and distal dural rings, of interest in cavernous sinus surgery. The Kassam's group (2014), with an endoscopic endonasal perspective, introduces the "paraclival segment," including the "lacerum segment" and part of the intracavernous ICA, and details surgical landmarks to minimize the risk of injury. Other classifications are also analyzed. This review through an interactive 3D tool provides virtual views of the ICA and becomes an innovative perspective to the segment classifications and neuroanatomy of the ICA and surrounding structures.
Collapse
|
27
|
Tayebi Meybodi A, Little AS, Vigo V, Benet A, Kakaizada S, Lawton MT. The pterygoclival ligament: a novel landmark for localization of the internal carotid artery during the endoscopic endonasal approach. J Neurosurg 2018; 130:1-11. [PMID: 29775148 DOI: 10.3171/2017.12.jns172435] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 12/05/2017] [Indexed: 11/06/2022]
Abstract
Objective The transpterygoid extension of the endoscopic endonasal approach provides exposure of the petrous apex, Meckel's cave, paraclival area, and the infratemporal fossa. Safe and efficient localization of the lacerum segment of the internal carotid artery (ICA) is a crucial part of such exposure. The aim of this study is to introduce a novel landmark for localization of the lacerum ICA. Methods Ten cadaveric heads were prepared for transnasal endoscopic dissection. The floor of the sphenoid sinus was drilled to expose an extension of the pharyngobasilar fascia between the sphenoid floor and the pterygoid process (the pterygoclival ligament). Several features of the pterygoclival ligament were assessed. In addition, 31 dry skulls were studied to assess features of the bony groove harboring the pterygoclival ligament. Results The pterygoclival ligament was identified bilaterally during drilling of the sphenoid floor in all specimens. The ligament started a few millimeters posterior to the posterior end of the vomer alae and invariably extended posterolaterally and superiorly to blend into the fibrous tissue around the lacerum ICA. The mean length of the ligament was 10.5 ± 1.7 mm. The mean distance between the anterior end of the ligament and midline was 5.2 ± 1.2 mm. The mean distance between the posterior end of the ligament and midline was 12.3 ± 1.4 mm. The bony pterygoclival groove was identified at the confluence of the vomer, pterygoid process of the sphenoid, and basilar part of the occipital bone, running from posterolateral to anteromedial. The mean length of the groove was 7.7 ± 1.8 mm. Its posterolateral end faced the anteromedial aspect of the foramen lacerum medial to the posterior end of the vidian canal. A clinical case illustration is also provided. Conclusions The pterygoclival ligament is a consistent landmark for localization of the lacerum ICA. It may be used as an adjunct or alternative to the vidian nerve to localize the ICA during endoscopic endonasal surgery.
Collapse
Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Andrew S Little
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Vera Vigo
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | - Arnau Benet
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Sofia Kakaizada
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California
| | - Michael T Lawton
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona; and
| |
Collapse
|
28
|
Valera-Melé M, Puigdellívol-Sánchez A, Mavar-Haramija M, Juanes-Méndez JA, San-Román L, de Notaris M, Prats-Galino A. A Novel and Freely Available Interactive 3d Model of the Internal Carotid Artery. J Med Syst 2018; 42:72. [DOI: 10.1007/s10916-018-0919-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 02/19/2018] [Indexed: 10/17/2022]
|
29
|
Yağmurlu K, Mooney MA, Almefty KK, Bozkurt B, Tanrıöver N, Little AS, Preul MC. An Alternative Endoscopic Anterolateral Route to Meckel's Cave: An Anatomic Feasibility Study Using a Sublabial Transmaxillary Approach. World Neurosurg 2018; 114:134-141. [PMID: 29510274 DOI: 10.1016/j.wneu.2018.02.128] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 02/20/2018] [Accepted: 02/22/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe an endoscopic anterolateral surgical route to the lateral portion of Meckel's cave. METHODS A sublabial transmaxillary transpterygoid approach was performed in 6 cadaveric heads (12 sides). A craniectomy was drilled between the foramen rotundum (FR) and foramen ovale (FO) with defined borders. Extradural dissection was performed up to the V2-V3 junction of the trigeminal ganglion. The working space was analyzed using anatomic measurements. RESULTS The approach allowed for extradural dissection to the lateral aspect of Meckel's cave and provided excellent exposure of V2, V3, and the V2-V3 junction at the gasserian ganglion. The mean distance between the FR and FO along the pterygoid process of the sphenoid bone was 21.3 ± 2.8 mm (range, 18-24.4 mm). The mean distance of V2 and V3 segments from their foramina to the gasserian ganglion junction was 12.0 ± 2.3 mm (range, 9.2-14.6 mm) and 15.2 ± 2.7 mm (range, 12.3-18.5 mm), respectively (6 sides). A potential working area (mean area, 89 mm2) is described. Its superior edge is from the FR to the V2-V3 junction at the gasserian ganglion, its inferior edge is from the FO to the V2-V3 junction at the gasserian ganglion, and its base is from the FO to the FR. The surgical anatomy of the infratemporal fossa, pterygopalatine fossa, and lateral Meckel's cave is highlighted. CONCLUSIONS An endoscopic anterolateral sublabial transmaxillary transpterygoid approach between the FR and FO avoids crossing critical neurovascular structures within the cavernous sinus and pterygopalatine fossa and can provide a safe surgical corridor for laterally based lesions in Meckel's cave.
Collapse
Affiliation(s)
- Kaan Yağmurlu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kaith K Almefty
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Baran Bozkurt
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Necmettin Tanrıöver
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
| |
Collapse
|
30
|
Komune N, Matsuo S, Miki K, Akagi Y, Kurogi R, Iihara K, Nakagawa T. Surgical Anatomy of the Eustachian Tube for Endoscopic Transnasal Skull Base Surgery: A Cadaveric and Radiologic Study. World Neurosurg 2018; 112:e172-e181. [PMID: 29325963 DOI: 10.1016/j.wneu.2018.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/29/2017] [Accepted: 01/03/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The endoscopic endonasal approach to the anatomically complex lateral skull base presents technical challenges. The use of the eustachian tube as a landmark to identify the petrous internal carotid artery has recently been reported, and this study aims to define the anatomic relationship between the eustachian tube and its surrounding structures using cadaveric dissection and radiologic analysis. METHODS To clarify the relationship of the eustachian tube with its surrounding structures, we performed endoscopic and microscopic dissection of 4 adult cadaveric heads and analyzed computed topography scans from 20 patients. RESULTS The eustachian tube is divided into the osseous and cartilaginous parts. The cartilaginous part can be further subdivided into the posterolateral, middle, and anteromedial parts, based on its relationship to the skull base. The eustachian tube is closely related to the pterygoid process of the sphenoid bone, the foramen lacerum, and the petrosal apex and is directed away from the oblique sagittal plane almost parallel to the vidian canal at 12.2° ± 6.2° (mean ± standard deviation). The relationship between the course of the vidian canal and the eustachian tube can aid the estimation of the anatomic course of the horizontal segment of the petrous carotid artery. CONCLUSIONS The eustachian tube is a useful landmark for predicting the course of the internal carotid artery when accessing the lateral skull base regions via an endonasal route. A profound understanding of the relationship between the eustachian tube and the surrounding skull base structures is important for endoscopic endonasal skull base surgeries.
Collapse
Affiliation(s)
- Noritaka Komune
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Satoshi Matsuo
- Department of Neurosurgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan
| | - Koichi Miki
- Department of Neurosurgery, Graduate School of Medical Sciences, Fukuoka University, Fukuoka, Japan
| | - Yojiro Akagi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryota Kurogi
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takashi Nakagawa
- Department of Otorhinolaryngology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| |
Collapse
|
31
|
Oakley GM, Ebenezer J, Hamizan A, Sacks PL, Rom D, Sacks R, Winder M, Davidson A, Teo C, Solares CA, Harvey RJ. Finding the Petroclival Carotid Artery: The Vidian-Eustachian Junction as a Reliable Landmark. J Neurol Surg B Skull Base 2017; 79:361-366. [PMID: 30009117 DOI: 10.1055/s-0037-1608650] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 09/10/2017] [Indexed: 10/18/2022] Open
Abstract
Introduction Identifying the internal carotid artery (ICA) when managing petroclival and infratemporal fossa pathology is essential for the skull base surgeon. The vidian nerve and eustachian tube (ET) cartilage come together at the foramen lacerum, the vidian-eustachian junction (VEJ). The ICA position, relative to the VEJ is described. Methods Endoscopic dissection of adult fresh-frozen cadaver ICAs and a case series of patients with petroclival pathology were performed. The relationship of the VEJ to the ICA horizontal segment, vertical segment, and second genu was assessed. The distance of the ICA second genu to VEJ was determined in coronal, axial, and sagittal planes. The length of the vidian nerve and ET was measured from the pterygopalatine fossa (PPF) and nasopharyngeal orifice to the VEJ. Results In this study, 10 cadaver dissections (82.3 ± 6.7 years, 40% female) were performed. The horizontal petrous ICA was at or behind VEJ in 100%, above VEJ in 100%, and lateral to VEJ in 80%. The vertical paraclival segment was at or behind VEJ in 100%, above in 100%, and medial in 100%. The second genu was at or behind VEJ in 100% (3.3 ± 2.4 mm), at or above in 100% (2.5 ± 1.6 mm), and medial in 100% (3.4 ± 2.0 mm). The VEJ was successfully used to locate the ICA in nine consecutive patients (53.3 ± 13.6 years, 55.6% female) where pathology was also present. The VEJ was 15.0 ± 6.0 mm from the ET and 17.4 ± 4.1 mm from the PPF. Conclusion The VEJ is an excellent landmark as it defines both superior and posterior limits when isolating the ICA in skull base surgery.
Collapse
Affiliation(s)
- Gretchen M Oakley
- Division of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, United States.,Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Jareen Ebenezer
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Aneeza Hamizan
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Department of Otolaryngology-Head and Neck Surgery, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Peta-Lee Sacks
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Darren Rom
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Raymond Sacks
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Mark Winder
- Department of Neurosurgery, St Vincent's Hospital, Sydney, Australia
| | - Andrew Davidson
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Hospital, Sydney, Australia
| | - C Arturo Solares
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, United States
| | - Richard J Harvey
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| |
Collapse
|
32
|
Dal Secchi MM, Dolci RLL, Teixeira R, Lazarini PR. An Analysis of Anatomic Variations of the Sphenoid Sinus and Its Relationship to the Internal Carotid Artery. Int Arch Otorhinolaryngol 2017; 22:161-166. [PMID: 29619106 PMCID: PMC5882364 DOI: 10.1055/s-0037-1607336] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 09/03/2017] [Indexed: 11/26/2022] Open
Abstract
Introduction
The sphenoid sinus (SS) has a high variability; its anatomical relations and variations must be well understood prior to the expanded endoscopic surgery (EES) at the skull base via the endonasal transsphenoidal approach. A feared complication is injury to the internal carotid artery (ICA).
Objective
To evaluate the anatomic variations of the SS and its relationship to the ICA using computed tomography (CT).
Methods
Cross-sectional retrospective study. Analysis of 90 patients' CT scans on axial, coronal and sagittal planes with 1 mm slices, evaluating lateral and posterior extensions of pneumatization of the SS, deviation of the sphenoid septum, presence of septations and their relationship to the parasellar and paraclival segments of the internal carotid artery (psICA and pcICA, respectively).
Results
The association between the protrusions of the psICA and the pcICA was statistically significant (
p
< 0.001), as was the association between the lateral extension of pneumatization of the SS and the protrusion of the psICA (
p
= 0.014). The presence of the posterior extension of pneumatization of the SS and protrusion of the pcICA occurred in 46% of the cases. Deviation of the sphenoid septum in the direction of the pcICA was present in 14% and dehiscence of the pcICA was seen in 3.6% of the cases.
Conclusion
Using the CT scan to recognize the type of extensions of pneumatization of the SS, the deviation of the sphenoid septum, and the presence of septations is beneficial to identify accurately the ICA and to reduce the risk of injury to it.
Collapse
Affiliation(s)
- Myrian Marajó Dal Secchi
- Department of Otorhinolaryngology, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil
| | - Ricardo Landini Lutaif Dolci
- Department of Otorhinolaryngology, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil
| | - Reginaldo Teixeira
- Department of Radiology, Irmandade da Santa Casa da Misericórdia de Santos, Santos, SP, Brazil
| | - Paulo Roberto Lazarini
- Department of Otorhinolaryngology, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil
| |
Collapse
|
33
|
Pérez de San Román-Mena L, Simal-Julián JA, Miranda-Lloret P, Sanromán-Álvarez P, Botella-Asunción C. Radiological Study of the Carotid-Clival Window and Its Application in Endoscopic Endonasal Expanded Approaches. World Neurosurg 2017; 104:356-360. [PMID: 28526643 DOI: 10.1016/j.wneu.2017.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 05/05/2017] [Accepted: 05/06/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND The surgical approach to the petrous apex (PA) and petroclival junction (PCJ) remains a challenge. The carotid-clival window (CCW) represents the widest window available to approach the PCJ from a mediolateral endoscopic route. Here we define the CCW radiologically in nonpathological conditions, to establish the anatomic variability of the PCJ, relate this variability to pneumatization patterns, and evaluate some technical concerns conditioned by the CCW. METHODS This was an analytical study of 10 multislice computed tomography scans from patients without SB pathology. Bilateral measures were taken at the roof and floor levels of the lacerum canal (LC) and its posterior projection over the PCJ (segments DE and QR). All measures were compared across different pneumatization patterns. RESULTS The DE and QR lengths were found to be the most important measures affecting the width of the CCW. Wide variability was observed, with a mean DE length of 8.52 mm (range, 2.4-12.8 mm) at the LC floor level and a mean QR length of 9.11 mm (range, 4.3-13.1 mm) at the LC roof level. The presence of retrocarotid pneumatization was statistically significantly associated with longer DE and QR segments. No differences were found among other pneumatization patterns. CONCLUSIONS The CCW varies widely among individuals. The presence of pneumatization behind the paraclival carotid represents an advantageous characteristic when planning an endoscopic approach to the PCJ.
Collapse
Affiliation(s)
| | | | - Pablo Miranda-Lloret
- Department of Neurosurgery, Hospital U. i P. La Fe. Fernando Abril Martorell, Valencia, Spain
| | - Pablo Sanromán-Álvarez
- Department of Neurosurgery, Hospital U. i P. La Fe. Fernando Abril Martorell, Valencia, Spain
| | - Carlos Botella-Asunción
- Department of Neurosurgery, Hospital U. i P. La Fe. Fernando Abril Martorell, Valencia, Spain
| |
Collapse
|
34
|
Dolci RLL, Ditzel Filho LFS, Goulart CR, Upadhyay S, Buohliqah L, Lazarini PR, Prevedello DM, Carrau RL. Anatomical nuances of the internal carotid artery in relation to the quadrangular space. J Neurosurg 2017; 128:174-181. [PMID: 28298027 DOI: 10.3171/2016.10.jns16381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the anatomical variations of the internal carotid artery (ICA) in relation to the quadrangular space (QS) and to propose a classification system based on the results. METHODS A total of 44 human cadaveric specimens were dissected endonasally under direct endoscopic visualization. During the dissection, the anatomical variations of the ICA and their relationship with the QS were noted. RESULTS The space between the paraclival ICAs (i.e., intercarotid space) can be classified as 1 of 3 different shapes (i.e., trapezoid, square, or hourglass) based on the trajectory of the ICAs. The ICA trajectories also directly influence the volumetric area of the QS. Based on its geometry, the QS was classified as one of the following: 1) Type A has the smallest QS area and is associated with a trapezoid intercarotid space, 2) Type B corresponds to the expected QS area (not minimized or enlarged) and is associated with a square intercarotid space, and 3) Type C has the largest QS area and is associated with an hourglass intercarotid space. CONCLUSIONS The different trajectories of the ICAs can modify the area of the QS and may be an essential parameter to consider for preoperative planning and defining the most appropriate corridor to reach Meckel's cave. In addition, ICA trajectories should be considered prior to surgery to avoid injuring the vessels.
Collapse
Affiliation(s)
- Ricardo L L Dolci
- Departments of1Otolaryngology-Head & Neck Surgery and.,3Department of Otolaryngology-Head & Neck Surgery, Santa Casa de Misericórida de São Paulo,Brazil
| | - Leo F S Ditzel Filho
- 2Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio; and
| | - Carlos R Goulart
- 2Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio; and
| | | | | | - Paulo R Lazarini
- 3Department of Otolaryngology-Head & Neck Surgery, Santa Casa de Misericórida de São Paulo,Brazil
| | - Daniel M Prevedello
- Departments of1Otolaryngology-Head & Neck Surgery and.,2Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio; and
| | - Ricardo L Carrau
- Departments of1Otolaryngology-Head & Neck Surgery and.,2Neurosurgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio; and
| |
Collapse
|
35
|
Abstract
The endoscopic resection of pterygopalatine and infratemporal fossa malignancies allows excellent visualization and manipulation of tissues in an anatomically complex area compared with open approaches. With less approach morbidity, endoscopic endonasal surgery allows an easier recovery and earlier transition to adjuvant radiotherapy. The endoscopic approach is minimal access but rarely minimally invasive. Surgeons should not hesitate to gain wide surgical exposure of the pterygopalatine, infratemporal fossa, and petrocavernous carotid artery to ensure comfortable maneuverability and easy visualization of the tumor and its normal tissue margins. This method maximizes the chances of complete resection and effective postoperative surveillance.
Collapse
|
36
|
Roxbury CR, Ishii M, Blitz AM, Reh DD, Gallia GL. Expanded Endonasal Endoscopic Approaches to the Skull Base for the Radiologist. Radiol Clin North Am 2017; 55:1-16. [PMID: 27890179 DOI: 10.1016/j.rcl.2016.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The cranial base is a complex 3-D region that contains critical neurovascular structures. Pathologies affecting this region represent some of the most challenging lesions to manage due to difficulty with access and risk of significant postoperative morbidity. With the development of expanded endonasal endoscopic approaches, skull base surgeons use the nose and paranasal sinuses as a corridor to access selected ventral skull base lesions. This review discusses high-resolution imaging in the evaluation of patients with skull base lesions considered for endonasal endoscopic surgery, summarizes various expanded endonasal endoscopic approaches, and provides examples of commonly used expanded endonasal endoscopic procedures.
Collapse
|
37
|
Shkarubo AN, Koval' KV, Dobrovol'skiy GF, Shkarubo MA, Karnaukhov VV, Kadashev BA, Andreev DN, Chernov IV, Gadzhieva OA, Aleshkina OY, Anisimova EA, Kalinin PL, Kutin MA, Fomichev DV, Sharipov OI, Ismailov DB, Selivanov ES. [Extended endoscopic endonasal posterior (transclival) approach to tumors of the clival region and ventral posterior cranial fossa. Part 1. Topographic and anatomical features of the clivus and adjacent structures]. Zh Vopr Neirokhir Im N N Burdenko 2017; 81:5-16. [PMID: 28914866 DOI: 10.17116/neiro20178145-16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE to describe the main topographic and anatomical features of the clival region and its adjacent structures for improvement and optimization of the extended endoscopic endonasal posterior (transclival) approach for resection of tumors of the clival region and ventral posterior cranial fossa. MATERIAL AND METHODS We performed a craniometric study of 125 human skulls and a topographic anatomical study of heads of 25 cadavers, the arterial and venous bed of which was stained with colored silicone (the staining technique was developed by the authors) to visualize bed features and individual variability. Currently, we have clinical material from more than 120 surgical patients with various skull base tumors of the clival region and ventral posterior cranial fossa (chordomas, pituitary adenomas, meningiomas, cholesteatomas, etc.) who were operated on using the endoscopic transclival approach. RESULTS We present the main anatomical landmarks and parameters of some anatomical structures that are required for performing the endoscopic endonasal posterior approach. The anatomical landmarks, such as the intradural openings of the abducens and glossopharyngeal nerves, may be used to arbitrarily divide the clival region into the superior, middle, and inferior thirds. The anatomical landmarks important for the surgeon, which are detected during a topographic anatomical study of the skull base, facilitate identification of the boundaries between the different clival portions and the C1 segments of the internal carotid arteries. The superior, middle, and inferior transclival approaches provide an access to the ventral surface of the upper, middle, and lower neurovascular complexes in the posterior cranial fossa. CONCLUSION The endoscopic transclival approach may be used to access midline tumors of the posterior cranial fossa. The approach is an alternative to transcranial approaches in surgical treatment of clival region lesions. This approach provides results comparable (and sometimes better) to those of the transcranial and transfacial approaches.
Collapse
Affiliation(s)
- A N Shkarubo
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - K V Koval'
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - M A Shkarubo
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - B A Kadashev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - D N Andreev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - I V Chernov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - O A Gadzhieva
- Burdenko Neurosurgical Institute, Moscow, Russia, Razumovskiy Saratov State Medical University, Saratov, Russia, Regional Clinical Hospital, Saratov, Russia
| | - O Yu Aleshkina
- Razumovskiy Saratov State Medical University, Saratov, Russia
| | - E A Anisimova
- Razumovskiy Saratov State Medical University, Saratov, Russia
| | - P L Kalinin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - M A Kutin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - D V Fomichev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - O I Sharipov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - D B Ismailov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | |
Collapse
|
38
|
Elhadi AM, Zaidi HA, Yagmurlu K, Ahmed S, Rhoton AL, Nakaji P, Preul MC, Little AS. Infraorbital nerve: a surgically relevant landmark for the pterygopalatine fossa, cavernous sinus, and anterolateral skull base in endoscopic transmaxillary approaches. J Neurosurg 2016; 125:1460-1468. [DOI: 10.3171/2015.9.jns151099] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Endoscopic transmaxillary approaches (ETMAs) address pathology of the anterolateral skull base, including the cavernous sinus, pterygopalatine fossa, and infratemporal fossa. This anatomically complex region contains branches of the trigeminal nerve and external carotid artery and is in proximity to the internal carotid artery. The authors postulated, on the basis of intraoperative observations, that the infraorbital nerve (ION) is a useful surgical landmark for navigating this region; therefore, they studied the anatomy of the ION and its relationships to critical neurovascular structures and the maxillary nerve (V2) encountered in ETMAs.
METHODS
Endoscopic anatomical dissections were performed bilaterally in 5 silicone-injected, formalin-fixed cadaveric heads (10 sides). Endonasal transmaxillary and direct transmaxillary (Caldwell-Luc) approaches were performed, and anatomical correlations were analyzed and documented. Stereotactic imaging of each specimen was performed to correlate landmarks and enable precise measurement of each segment.
RESULTS
The ION was readily identified in the roof of the maxillary sinus at the beginning of the surgical procedure in all specimens. Anatomical dissections of the ION and the maxillary branch of the trigeminal nerve (V2) to the cavernous sinus suggested that the ION/V2 complex has 4 distinct segments that may have implications in endoscopic approaches: 1) Segment I, the cutaneous segment of the ION and its terminal branches (5–11 branches) to the face, distal to the infraorbital foramen; 2) Segment II, the orbitomaxillary segment of the ION within the infraorbital canal from the infraorbital foramen along the infraorbital groove (length 12 ± 3.2 mm); 3) Segment III, the pterygopalatine segment within the pterygopalatine fossa, which starts at the infraorbital groove to the foramen rotundum (13 ± 2.5 mm); and 4) Segment IV, the cavernous segment from the foramen rotundum to the trigeminal ganglion (15 ± 4.1 mm), which passes in the lateral wall of the cavernous sinus. The relationship of the ION/V2 complex to the contents of the cavernous sinus, carotid artery, and pterygopalatine fossa is described in the text.
CONCLUSIONS
The ION/V2 complex is an easily identifiable and potentially useful surgical landmark to the foramen rotundum, cavernous sinus, carotid artery, pterygopalatine fossa, and anterolateral skull base during ETMAs.
Collapse
Affiliation(s)
- Ali M. Elhadi
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Hasan A. Zaidi
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Kaan Yagmurlu
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Shah Ahmed
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Albert L. Rhoton
- 2Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Peter Nakaji
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Mark C. Preul
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Andrew S. Little
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| |
Collapse
|
39
|
Lin BJ, Chung TT, Lin MC, Lin C, Hueng DY, Chen YH, Hsia CC, Ju DT, Ma HI, Liu MY, Tang CT. Quantitative analysis of anatomical relationship between cavernous segment internal carotid artery and pituitary macroadenoma. Medicine (Baltimore) 2016; 95:e5027. [PMID: 27741111 PMCID: PMC5072938 DOI: 10.1097/md.0000000000005027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cavernous segment internal carotid artery (CSICA) injury during endoscopic transsphenoidal surgery for pituitary tumor is rare but fatal. The aim of this study is to investigate anatomical relationship between pituitary macroadenoma and corresponding CSICA using quantitative means with a sense to improve safety of surgery.In this retrospective study, a total of 98 patients with nonfunctioning pituitary macroadenomas undergoing endoscopic transsphenoidal surgeries were enrolled from 2005 to 2014. Intercarotid distances between bilateral CSICAs were measured in the 4 coronal levels, namely optic strut, convexity of carotid prominence, median sella turcica, and dorsum sellae. Parasellar extension was graded and recorded by Knosp-Steiner classification.Our findings indicated a linear relationship between size of pituitary macroadenoma and intercarotid distance over CSICA. The correlation was absent in pituitary macroadenoma with Knosp-Steiner grade 4 parasellar extension.Bigger pituitary macroadenoma makes more lateral deviation of CSICA. While facing larger tumor, sufficient bony graft is indicated for increasing surgical field, working area and operative safety.
Collapse
Affiliation(s)
- Bon-Jour Lin
- Department of Neurological Surgery, Tri-Service General Hospital
- Correspondence: Bon-Jour Lin, Department of Neurologic Surgery, Tri-Service General Hospital, Neihu, Taipei, Taiwan, R.O.C. (e-mail: )
| | - Tzu-Tsao Chung
- Department of Neurological Surgery, Tri-Service General Hospital
| | - Meng-Chi Lin
- Department of Neurological Surgery, Tri-Service General Hospital
| | - Chin Lin
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Dueng-Yuan Hueng
- Department of Neurological Surgery, Tri-Service General Hospital
| | - Yuan-Hao Chen
- Department of Neurological Surgery, Tri-Service General Hospital
| | - Chung-Ching Hsia
- Department of Surgery, Tri-Service General Hospital Songshan Branch
| | - Da-Tong Ju
- Department of Neurological Surgery, Tri-Service General Hospital
| | - Hsin-I Ma
- Department of Neurological Surgery, Tri-Service General Hospital
| | - Ming-Ying Liu
- Department of Neurological Surgery, Tri-Service General Hospital
| | - Chi-Tun Tang
- Department of Neurological Surgery, Tri-Service General Hospital
| |
Collapse
|
40
|
Abdulrauf SI, Ashour AM, Marvin E, Coppens J, Kang B, Hsieh TYY, Nery B, Penanes JR, Alsahlawi AK, Moore S, Abou Al-Shaar H, Kemp J, Chawla K, Sujijantarat N, Najeeb A, Parkar N, Shetty V, Vafaie T, Antisdel J, Mikulec TA, Edgell R, Lebovitz J, Pierson M, Pires de Aguiar PH, Buchanan P, Di Cosola A, Stevens G. Proposed clinical internal carotid artery classification system. J Craniovertebr Junction Spine 2016; 7:161-70. [PMID: 27630478 PMCID: PMC4994148 DOI: 10.4103/0974-8237.188412] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Numerical classification systems for the internal carotid artery (ICA) are available, but modifications have added confusion to the numerical systems. Furthermore, previous classifications may not be applicable uniformly to microsurgical and endoscopic procedures. The purpose of this study was to develop a clinically useful classification system. MATERIALS AND METHODS We performed cadaver dissections of the ICA in 5 heads (10 sides) and evaluated 648 internal carotid arteries with computed tomography angiography. We identified specific anatomic landmarks to define the beginning and end of each ICA segment. RESULTS The ICA was classified into eight segments based on the cadaver and imaging findings: (1) Cervical segment; (2) cochlear segment (ascending segment of the ICA in the temporal bone) (relation of the start of this segment to the base of the styloid process: Above, 425 sides [80%]; below, 2 sides [0.4%]; at same level, 107 sides [20%]; P < 0.0001) (relation of cochlea to ICA: Posterior, 501 sides [85%]; posteromedial, 84 sides [14%]; P < 0.0001); (3) petrous segment (horizontal segment of ICA in the temporal bone) starting at the crossing of the eustachian tube superolateral to the ICA turn in all 10 samples; (4) Gasserian-Clival segment (ascending segment of ICA in the cavernous sinus) starting at the petrolingual ligament (PLL) (relation to vidian canal on imaging: At same level, 360 sides [63%]; below, 154 sides [27%]; above, 53 sides [9%]; P < 0.0001); in this segment, the ICA projected medially toward the clivus in 275 sides (52%) or parallel to the clivus with no deviation in 256 sides (48%; P < 0.0001); (5) sellar segment (medial loop of ICA in the cavernous sinus) starting at the takeoff of the meningeal hypophyseal trunk (ICA was medial into the sella in 271 cases [46%], lateral without touching the sella in 127 cases [23%], and abutting the sella in 182 cases [31%]; P < 0.0001); (6) sphenoid segment (lateral loop of ICA within the cavernous sinus) starting at the crossing of the fourth cranial nerve on the lateral aspect of the cavernous ICA and located directly lateral to the sphenoid sinus; (7) ring segment (ICA between the 2 dural rings) starting at the crossing of the third cranial nerve on the lateral aspect of the ICA; (8) cisternal segment starting at the distal dural ring. CONCLUSIONS The classification may be applied uniformly to all skull base surgical approaches including lateral microsurgical and ventral endoscopic approaches, obviating the need for 2 separate classification systems. The classification allows extrapolation of relevant clinical information because each named segment may indicate potential surgical risk to specific structures.
Collapse
Affiliation(s)
- Saleem I Abdulrauf
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Ahmed M Ashour
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Eric Marvin
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Jeroen Coppens
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Brian Kang
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Tze Yu Yeh Hsieh
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Breno Nery
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Juan R Penanes
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Aysha K Alsahlawi
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Shawn Moore
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Hussam Abou Al-Shaar
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Joanna Kemp
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Kanika Chawla
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Nanthiya Sujijantarat
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Alaa Najeeb
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Nadeem Parkar
- Department of Radiology, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Vilaas Shetty
- Department of Radiology, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Tina Vafaie
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Jastin Antisdel
- Department of Head and Neck Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Tony A Mikulec
- Department of Head and Neck Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Randall Edgell
- Department of Neurology, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Jonathan Lebovitz
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Matt Pierson
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | | | - Paula Buchanan
- Center for Outcomes Research, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Angela Di Cosola
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| | - George Stevens
- Department of Neurological Surgery, Saint Louis University, Saint Louis, Missouri, United States of America
| |
Collapse
|
41
|
Mattavelli D, Bolzoni Villaret A, Ferrari M, Ravanelli M, Rampinelli V, Lancini D, Rodella LF, Fontanella M, Maroldi R, Nicolai P, Doglietto F. Different Perspectives of Internal Carotid Artery in Transnasal Endoscopic Surgery. World Neurosurg 2016; 95:222-228. [PMID: 27530718 DOI: 10.1016/j.wneu.2016.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 08/03/2016] [Accepted: 08/05/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Several endoscopic landmarks for the internal carotid artery (ICA) have been identified, but they have always been proposed in a "static" perspective. The aim of this study was to investigate how the surgical corridor and optical distortion can influence the perception of carotid landmarks in transnasal endoscopic surgery. METHODS Computed tomography images of skulls in 20 subjects were analyzed. The petrous carotid angle (PCA) was calculated as the angle between the petrous carotid axis and the coronal plane connecting stylomastoid foramina. The angle of incidence (AI) on the anterior carotid genu of 3 different surgical corridors (contralateral nostril, ipsilateral nostril, and transmaxillary ipsilateral route) was evaluated. PCA, AI, and their differences were studied by Spearman's correlation test. Two cadaver heads were dissected, simulating the studied surgical corridors. The fish-eye effect was empirically quantified. RESULTS Mean PCA was 31° (range, 21-41°). PCA and AI are linked by an inverse proportion relationship. A transmaxillary approach always ensures the highest value of AI on the target. The cadaveric dissection qualitatively confirmed the radiologic data. The fish-eye effect can cause a compression of distance perception as high as 37%. CONCLUSIONS The surgical corridor and endoscope optic distortion can influence ICA visualization and the perception of its anatomic landmarks. In a 2-nostril, 4-handed approach, it is advisable to place the endoscope and instrument for dissection in the nostril that is ipsilateral to the lesion. Awareness of the different perspectives and related optical distortions is essential when working in proximity to the ICA.
Collapse
Affiliation(s)
- Davide Mattavelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy.
| | - Andrea Bolzoni Villaret
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Marco Ferrari
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Marco Ravanelli
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Vittorio Rampinelli
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Davide Lancini
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Luigi Fabrizio Rodella
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Marco Fontanella
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Roberto Maroldi
- Unit of Radiology, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Piero Nicolai
- Unit of Otorhinolaryngology-Head and Neck Surgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Francesco Doglietto
- Unit of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| |
Collapse
|
42
|
Simon F, Vacher C, Herman P, Verillaud B. Surgical landmarks of the nasopharyngeal internal carotid using the maxillary swing approach: A cadaveric study. Laryngoscope 2016; 126:1562-6. [DOI: 10.1002/lary.25870] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 12/08/2015] [Accepted: 12/17/2015] [Indexed: 12/28/2022]
Affiliation(s)
- François Simon
- Department of Otorhinolaryngology; AP-HP, Lariboisière Hospital, Paris Diderot University; Paris France
| | - Christian Vacher
- Department of Maxillofacial Surgery; AP-HP, Beaujon Hospital, Paris Diderot University; Paris France
| | - Philippe Herman
- Department of Otorhinolaryngology; AP-HP, Lariboisière Hospital, Paris Diderot University; Paris France
| | - Benjamin Verillaud
- Department of Otorhinolaryngology; AP-HP, Lariboisière Hospital, Paris Diderot University; Paris France
| |
Collapse
|
43
|
Sanmillan JL, Lawton MT, Rincon-Torroella J, El-Sayed IH, Zhang X, Meybodi AT, Gabarros A, Benet A. Assessment of the Endoscopic Endonasal Transclival Approach for Surgical Clipping of Anterior Pontine Anterior-Inferior Cerebellar Artery Aneurysms. World Neurosurg 2016; 89:368-75. [PMID: 26852706 DOI: 10.1016/j.wneu.2016.01.081] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 01/26/2016] [Accepted: 01/27/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Aneurysms of the anterior pontine segment of the anterior-inferior cerebellar artery (AICA) are uncommon. Their treatment is challenging because critical neurovascular structures are adjacent to it and the available surgical corridors are narrow and deep. Although endoscopic endonasal approaches are accepted for treating midline skull base lesions, their role in the treatment vascular lesions remains undefined. The present study is aimed to assess the anatomic feasibility of the endoscopic endonasal transclival (EET) approach for treating anterior pontine AICA aneurysms and compare it with the subtemporal anterior transpetrosal (SAT) approach. METHODS Twelve cadaveric specimens were prepared for surgical simulation. The AICAs were exposed using both EET and SAT approaches. Surgical window area and the length of the exposed artery were measured. The distance from the origin of the artery to the clip applied for proximal control was measured. The number of AICA perforators exposed and the anatomic features of each AICA were recorded. RESULTS The EET approach provided a wider surgical window area compared with the SAT (P < 0.001). More AICA perforators were visualized using the EET approach (P < 0.05). To obtain proximal control of the AICA, an aneurysm clip could be applied closer to the origin of AICA using EET (0.2 ± 0.42 mm) compared with SAT (6.26 ± 3.4 mm) (P < 0.001). CONCLUSION Clipping anterior pontine AICA aneurysms using the EET approach is feasible. Compared with SAT, the EET approach provides advantages in surgical window area, ensuring proximal control before aneurysm dissection, visualization of perforating branches, and better proximal control.
Collapse
Affiliation(s)
| | | | | | | | - Xin Zhang
- University of California, San Francisco, California, USA
| | | | | | - Arnau Benet
- University of California, San Francisco, California, USA.
| |
Collapse
|
44
|
Jhawar SS, Nunez M, Pacca P, Voscoboinik DS, Truong H. Craniovertebral junction 360°: A combined microscopic and endoscopic anatomical study. J Craniovertebr Junction Spine 2016; 7:204-216. [PMID: 27891029 PMCID: PMC5111321 DOI: 10.4103/0974-8237.193270] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives: Craniovertebral junction (CVJ) can be approached from various corridors depending on the location and extent of disease. A three-dimensional understanding of anatomy of CVJ is paramount for safe surgery in this region. Aim of this cadaveric study is to elucidate combined microscopic and endoscopic anatomy of critical neurovascular structures in this area in relation to bony and muscular landmarks. Materials and Methods: Eight fresh-frozen cadaveric heads injected with color silicon were used for this study. A stepwise dissection was done from anterior, posterior, and lateral sides with reference to bony and muscular landmarks. Anterior approach was done endonasal endoscopically. Posterior and lateral approaches were done with a microscope. In two specimens, both anterior and posterior approaches were done to delineate the course of vertebral artery and lower cranial nerves from ventral and dorsal aspects. Results: CVJ can be accessed through three corridors, namely, anterior, posterior, and lateral. Access to clivus, foreman magnum, occipital cervical joint, odontoid, and atlantoaxial joint was studied anteriorly with an endoscope. Superior and inferior clival lines, supracondylar groove, hypoglossal canal, arch of atlas and body of axis, and occipitocervical joint act as useful bony landmarks whereas longus capitis and rectus capitis anterior are related muscles to this approach. In posterior approach, spinous process of axis, arch of atlas, C2 ganglion, and transverse process of atlas and axis are bony landmarks. Rectus capitis posterior major, superior oblique, inferior oblique, and rectus capitis lateralis (RCLa) are muscles related to this approach. Occipital condyles, transverse process of atlas, and jugular tubercle are main bony landmarks in lateral corridor whereas RCLa and posterior belly of digastric muscle are the main muscular landmarks. Conclusion: With advances in endoscopic and microscopic techniques, access to lesions and bony anomalies around CVJ is becoming easier and straightforward. A combination of microscopic and endoscopic techniques is more useful to understand this anatomy and may aid in the development of future combined approaches.
Collapse
Affiliation(s)
- Sukhdeep Singh Jhawar
- Department of Neurosurgery, Satguru Partap Singh Hospital, Ludhiana, Punjab, India; Department of Neurosurgery, Surgical Neuroanatomy Lab, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Maximiliano Nunez
- Department of Neurosurgery, Surgical Neuroanatomy Lab, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Paolo Pacca
- Department of Neurosurgery, Surgical Neuroanatomy Lab, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Daniel Seclen Voscoboinik
- Department of Neurosurgery, Surgical Neuroanatomy Lab, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Huy Truong
- Department of Neurosurgery, Surgical Neuroanatomy Lab, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
45
|
Abstract
OBJECTIVE The surgical approach to lesions involving the inferior petrous apex (IPA) is still challenging. The purpose of this study is to demonstrate the anatomical features of the IPA and to assess the applicability of an endoscopic endonasal approach through the foramen lacerum (translacerum approach) to the IPA. METHODS The surgical simulation of the endoscopic endonasal translacerum approach was conducted in 3 cadaver heads. The same technique was applied in 4 patients harboring tumors involving the IPA (3 chordomas and 1 chondro-sarcoma). RESULTS By removing the fibrocartilaginous component of the foramen lacerum, a triangular space was created between the anterior genu of the petrous portion of the carotid artery and the eustachian tube, through which the IPA could be approached. The range of the surgical maneuver reached laterally up to the internal auditory canal, jugular foramen, and posterior vertical segment of the petrous portion of the carotid artery. In clinical application, the translacerum approach provided sufficient space to handle tumors at the IPA. Gross-total and partial removal was achieved in 3 and 1 cases, respectively, without permanent surgery-related morbidity and mortality. CONCLUSIONS The endoscopic endonasal translacerum approach provides reliable access to the IPA. It is indicated alone for lesions confined to the IPA and in combination with other approaches for more extensive lesions.
Collapse
Affiliation(s)
- Masaaki Taniguchi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Nobuyuki Akutsu
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Katsu Mizukawa
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Masaaki Kohta
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Hidehito Kimura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| |
Collapse
|
46
|
|
47
|
Affiliation(s)
- Almaz Kurbanov
- Departments of *Neurosurgery and ‡Otolaryngology-Head and Neck Surgery, University of Cincinnati (UC) College of Medicine, §Comprehensive Stroke Center at UC Neuroscience Institute ¶Mayfield Clinic, Cincinnati, Ohio; ‖Department of Neurological Surgery, University of California San Francisco, San Francisco, California; #Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | | |
Collapse
|
48
|
Affiliation(s)
- Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward R Laws
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
49
|
Cavallo LM, Solari D, Cappabianca P. Further classification to gain much more clarification: an evolving scheme of the internal carotid artery as seen from the endoscopic endonasal perspective. World Neurosurg 2014; 83:160-1. [PMID: 25451810 DOI: 10.1016/j.wneu.2014.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 10/25/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Luigi M Cavallo
- Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy.
| | - Domenico Solari
- Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Paolo Cappabianca
- Department of Neurological Sciences, Division of Neurosurgery, Università degli Studi di Napoli Federico II, Naples, Italy
| |
Collapse
|