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Mignucci-Jiménez G, Xu Y, On TJ, Abramov I, Houlihan LM, Rahmani R, Koskay G, Hanalioglu S, Meybodi AT, Lawton MT, Preul MC. Toward an optimal cadaveric brain model for neurosurgical education: assessment of preservation, parenchyma, vascular injection, and imaging. Neurosurg Rev 2024; 47:190. [PMID: 38658446 DOI: 10.1007/s10143-024-02363-7] [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: 12/01/2023] [Revised: 02/13/2024] [Accepted: 03/16/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE We assessed types of cadaveric head and brain tissue specimen preparations that are used in a high throughput neurosurgical research laboratory to determine optimal preparation methods for neurosurgical anatomical research, education, and training. METHODS Cadaveric specimens (N = 112) prepared using different preservation and vascular injection methods were imaged, dissected, and graded by 11 neurosurgeons using a 21-point scale. We assessed the quality of tissue and preservation in both the anterior and posterior circulations. Tissue quality was evaluated using a 9-point magnetic resonance imaging (MRI) scale. RESULTS Formalin-fixed specimens yielded the highest scores for assessment (mean ± SD [17.0 ± 2.8]) vs. formalin-flushed (17.0 ± 3.6) and MRI (6.9 ± 2.0). Cadaver assessment and MRI scores were positively correlated (P < 0.001, R2 0.60). Analysis showed significant associations between cadaver assessment scores and specific variables: nonformalin fixation (β = -3.3), preservation within ≤72 h of death (β = 1.8), and MRI quality score (β = 0.7). Formalin-fixed specimens exhibited greater hardness than formalin-flushed and nonformalin-fixed specimens (P ≤ 0.006). Neurosurgeons preferred formalin-flushed specimens injected with colored latex. CONCLUSION For better-quality specimens for neurosurgical education and training, formalin preservation within ≤72 h of death was preferable, as was injection with colored latex. Formalin-flushed specimens more closely resembled live brain parenchyma. Assessment scores were lower for preparation techniques performed > 72 h postmortem and for nonformalin preservation solutions. The positive correlation between cadaver assessment scores and our novel MRI score indicates that donation organizations and institutional buyers should incorporate MRI as a screening tool for the selection of high-quality specimens.
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Affiliation(s)
- Giancarlo Mignucci-Jiménez
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - Yuan Xu
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - Thomas J On
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - Irakliy Abramov
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - Lena Mary Houlihan
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - Redi Rahmani
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - Grant Koskay
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - Sahin Hanalioglu
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - Ali Tayebi Meybodi
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - Michael T Lawton
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
- Robert F. Spetzler Chair in Neuroscience, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA
| | - Mark C Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA.
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Castillo AL, Meybodi AT, Liu JK. Jugular Foramen Tumors: Surgical Strategies and Representative Cases. Brain Sci 2024; 14:182. [PMID: 38391756 PMCID: PMC10886589 DOI: 10.3390/brainsci14020182] [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: 12/10/2023] [Revised: 02/07/2024] [Accepted: 02/15/2024] [Indexed: 02/24/2024] Open
Abstract
(1) Background: Jugular foramen tumors are complex lesions due to their relationship with critical neurovascular structures within the skull base. It is necessary to have a deep knowledge of the anatomy of the jugular foramen and its surroundings to understand each type of tumor growth pattern and how it is related to the surrounding neurovascular structures. This scope aims to provide a guide with the primary surgical approaches to the jugular foramen and familiarize the neurosurgeons with the anatomy of the region. (2) Methods and (3) Results: A comprehensive description of the surgical approaches to jugular foramen tumors is summarized and representative cases for each tumor type is showcased. (4) Conclusions: Each case should be carefully assessed to find the most suitable approach for the patient, allowing the surgeon to remove the tumor with minimal neurovascular damage. The combined transmastoid retro- and infralabyrinthine transjugular transcondylar transtubercular high cervical approach can be performed in a stepwise fashion for the resection of complex jugular foramen tumors.
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Affiliation(s)
- Andrea L Castillo
- Department of Neurological Surgery, New Jersey Medical School, Newark, NJ 07103, USA
- Department of Neurosurgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, NJ 07039, USA
| | - Ali Tayebi Meybodi
- Department of Neurological Surgery, New Jersey Medical School, Newark, NJ 07103, USA
- Department of Neurosurgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, NJ 07039, USA
| | - James K Liu
- Department of Neurosurgery, Cooperman Barnabas Medical Center, RWJ Barnabas Health, Livingston, NJ 07039, USA
- Skull Base Institute of New Jersey, Neurosurgeons of New Jersey, Livingston, NJ 07039, USA
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Zhao X, Evans AR, Tayebi Meybodi A, Hopkins N, Bowen I, Jen SS, Preul MC, Balsara K. Arteriovenous malformation with unique drainage through the emissary vein of the foramen ovale: illustrative case. J Neurosurg Case Lessons 2024; 7:CASE23620. [PMID: 38224585 DOI: 10.3171/case23620] [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] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 11/27/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND As part of the laterotrigeminal venous system (LTVS), the emissary vein of the foramen ovale (EVFO) is an underrecognized venous structure communicating between the cavernous sinus and pterygoid plexus. The sphenobasal sinus is an anatomical variation of the sphenoparietal sinus that drains directly into the EVFO. The authors present the case of a ruptured arteriovenous malformation (AVM) with a unique drainage pattern through the sphenobasal sinus and EVFO. OBSERVATIONS A 9-year-old female initially presented with loss of consciousness and was subsequently found to have a ruptured AVM in the left basal frontal area. She underwent an immediate decompressive hemicraniectomy, with a computed tomography angiogram demonstrating a unique anatomical variation in which the sphenobasal sinus communicated with the EVFO and LTVS. The final venous drainage returned to the pterygoid plexus and external jugular vein. Postoperatively, the patient made a substantial recovery, with generalized right-sided weakness remaining as the sole deficit. LESSONS The authors present the case of a ruptured AVM with unique venous drainage into the sphenobasal sinus and EVFO, for which the current literature remains limited. As exemplified by this illustrative case, technique modification may be warranted in the setting of this unique anatomical variation to avoid venous sinus injury.
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Affiliation(s)
- Xiaochun Zhao
- 1Division of Pediatric Neurosurgery, Oklahoma Children's Hospital, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
| | - Alexander R Evans
- 1Division of Pediatric Neurosurgery, Oklahoma Children's Hospital, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
| | - Ali Tayebi Meybodi
- 2The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nicholas Hopkins
- 1Division of Pediatric Neurosurgery, Oklahoma Children's Hospital, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
| | - Ira Bowen
- 1Division of Pediatric Neurosurgery, Oklahoma Children's Hospital, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
| | - Shyian S Jen
- 1Division of Pediatric Neurosurgery, Oklahoma Children's Hospital, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
| | - Mark C Preul
- 2The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Karl Balsara
- 1Division of Pediatric Neurosurgery, Oklahoma Children's Hospital, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
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Tayebi Meybodi A, Mignucci-Jiménez G, Xu Y, Preul MC. Artery of Uchimura: origin and evolution of identification of the vascular supply to the hippocampus. J Neurosurg 2023; 139:1128-1139. [PMID: 37086167 DOI: 10.3171/2023.2.jns221963] [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: 08/24/2022] [Accepted: 02/02/2023] [Indexed: 04/03/2023]
Abstract
In 1928, neuroscientist Yushi Uchimura (1897-1980) published a landmark study detailing the hippocampal vasculature. Working in Walther Spielmeyer's Munich laboratory (1925-1927), Uchimura sought evidence for a vascular theory of Ammon's horn sclerosis (AHS). He described an artery supplying the vulnerable sector of the hippocampus, where pathognomonic changes of AHS were noted, and characterized the artery as particularly susceptible to circulatory disturbances. Discovery of this artery led to new concepts and new terminology pertaining to the hippocampus. In addition to having a distinguished career in psychiatry and academia (including a position as University of Tokyo dean), Uchimura was, before attending medical school, one of Japan's best baseball pitchers; he was eventually named Nippon Professional Baseball Organization commissioner and inducted into the Japan Baseball Hall of Fame. Uchimura's description of hippocampal vasculature, which is still subject to debate after nearly a century, brought international attention to AHS and epilepsy and showed the hippocampal vasculature to be variable and vulnerable; important considerations for later neurosurgeons in the development of selective mesial temporal surgery. Prominent figures in neurosurgery have since developed classification systems for the hippocampal vasculature in which the artery of Uchimura remains central. Perhaps no other brain artery has been the nexus for such intense investigation and debate about its association to structure, function, disease, and treatment methodology.
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Affiliation(s)
- Ali Tayebi Meybodi
- 1Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey; and
| | - Giancarlo Mignucci-Jiménez
- 2Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Yuan Xu
- 2Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark C Preul
- 2Department of Neurosurgery, The Loyal and Edith Davis Neurosurgical Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Kumarapuram S, Elmogazy O, Mokhtari P, Goldstein I, Tayebi Meybodi A. Do overlapping neurosurgical procedures affect patient outcomes? A systematic review and meta-analysis. Neurosurg Rev 2023; 46:92. [PMID: 37072635 DOI: 10.1007/s10143-023-01993-7] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/20/2023] [Accepted: 04/06/2023] [Indexed: 04/20/2023]
Abstract
Overlapping surgery (OS) is a common practice in neurosurgery that has recently come under scrutiny. This study includes a systematic review and meta-analysis on articles evaluating the effects of OS on patient outcomes. PubMed and Scopus were searched for studies that analyzed outcome differences between overlapping and non-overlapping neurosurgical procedures. Study characteristics were extracted, and random-effects meta-analyses were performed to analyze the primary outcome (mortality) and secondary outcomes (complications, 30-day readmissions, 30-day operating room returns, home discharge, blood loss, and length of stay). Mantel-Haenszel tests were completed for binary outcomes, whereas the inverse variance tests were conducted for continuous outcomes. Heterogeneity was measured using the I2 and X2 tests. The Egger's test was conducted to evaluate publication bias. Eight of 61 non-duplicate studies were included. Overall, 21,249 patients underwent non-OS (10,504 female) and 15,863 patients underwent OS (8393 female). OS was associated with decreased mortality (p = 0.002), 30-day returns to OR (p < 0.001), and blood loss (p < 0.001) along with increased home discharges (p < 0.001). High heterogeneity was observed for home discharge (p = 0.002) and length of stay (p < 0.001). No publication bias was observed. OS was not associated with worse patient outcomes compared to non-OS. However, considering multiple sources of limitation in the methodology of the included studies (such as limited number of studies, reports originating from mostly high-volume academic centers, discrepancy in the definition of "critical portion(s)" of the surgery across studies, and selection bias), extra caution is advised in interpretation of our results and further focused studies are warranted.
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Affiliation(s)
- Siddhant Kumarapuram
- Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Rutgers University, New Brunswick, NJ, USA
| | | | - Pooneh Mokhtari
- Department of Neurosurgery, Rutgers New Jersey Medical School, 90 Bergen Street, Newark, NJ, 07103, USA
| | - Ira Goldstein
- Department of Neurosurgery, Rutgers New Jersey Medical School, 90 Bergen Street, Newark, NJ, 07103, USA
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Rutgers New Jersey Medical School, 90 Bergen Street, Newark, NJ, 07103, USA.
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Rahman RK, Majmundar N, San A, Sanmugananthan P, Berke C, Lang SS, Meybodi AT, Gajjar AA, Liu JK. Surgical Outcomes of Awake Craniotomy for Treatment of Arteriovenous Malformations in Eloquent Cortex: A Systematic Review. World Neurosurg 2023; 175:17-30. [PMID: 37004885 DOI: 10.1016/j.wneu.2023.03.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/24/2023] [Accepted: 03/25/2023] [Indexed: 04/01/2023]
Abstract
OBJECTIVE Arteriovenous malformations (AVM) located in eloquent brain regions are historically associated with a poor prognosis. Awake craniotomy (AC) with the adjunct of brain mapping has the potential of identifying non-eloquent gyri to maximize resection, thereby theoretically decreasing the risk of neurologic deficits. With limited evidence regarding the efficacy of AC in treatment of eloquent AVMs, this review aims to investigate its surgical outcomes. METHODS A systematic search in the PubMed database was performed to identify all relevant studies up to February 2022. RESULTS 13 studies were extracted for quantitative analysis, yielding a total of 46 patients. The mean age was 34.1 years, and most patients were female (54.8%). Seizures were the most frequently reported presenting symptom (41%, 19/46 cases). Spetzler-Martin Grade III was the most prevalent (45.9%, 17 cases) with a mean nidus size of 32.6 mm. Seventy-four percent of AVMs were located on the left-side, with the frontal lobe being the most common location (30%, 14/46 cases). The most common eloquent regions were language (47.8%, 22/46 cases), motor (17.4%, 8/46 cases), and language + motor cortices (13.1%, 6/46 cases). Complete resection of AVM was achieved in 41 patients (89%). Intraoperative complications occurred in 14/46 cases (30.4%) with transient postoperative neurologic deficits in 14 patients (30.4%). CONCLUSION AC may enable precise microsurgical excision of eloquent AVMs with preservation of critical brain functions. Risk factors for poor outcomes include eloquent AVMs located in the language + motor regions and the occurrence of intraoperative complications such as seizures/hemorrhage.
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Tayebi Meybodi A, Mignucci-Jiménez G, Lawton MT, Liu JK, Preul MC, Sun H. Comprehensive microsurgical anatomy of the middle cranial fossa: Part II-neurovascular anatomy. Front Surg 2023; 10:1132784. [PMID: 37035563 PMCID: PMC10080008 DOI: 10.3389/fsurg.2023.1132784] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/13/2023] [Indexed: 04/11/2023] Open
Abstract
In order to master the surgical approaches to the middle cranial fossa, the surgeon needs to understand the relevant bony anatomy. However, she/he also needs to have a clear and sound understanding of the neural and vascular anatomy because, oftentimes, the osseous anatomy (except for the optic apparatus) should be removed to expose and protect the neurovascular anatomy. This is the second of a two-part article discussing the neurovascular anatomy of the middle cranial fossa. A brief discussion of the surgical approaches follows.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, United States
- Correspondence: Ali Tayebi Meybodi
| | - Giancarlo Mignucci-Jiménez
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - James K. Liu
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, United States
- Departments of Neurosurgery and Otolaryngology, Robert Wood Johnson Barnabas Health, Newark, NJ, United States
| | - Mark C. Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Hai Sun
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, United States
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
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Tayebi Meybodi A, Mignucci-Jiménez G, Lawton MT, Liu JK, Preul MC, Sun H. Comprehensive microsurgical anatomy of the middle cranial fossa: Part I-Osseous and meningeal anatomy. Front Surg 2023; 10:1132774. [PMID: 37035561 PMCID: PMC10080110 DOI: 10.3389/fsurg.2023.1132774] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
The middle cranial fossa is one of the most complex regions in neurosurgery and otolaryngology-in fact, the practice of skull base surgery originated from the need to treat pathologies in this region. Additionally, great neurosurgeons of our present and past are remembered for their unique methods of treating diseases in the middle fossa. The following article reviews the surgical anatomy of the middle fossa. The review is divided into the anatomy of the bones, dura, vasculature, and nerves-in two parts. Emphasis is paid to their neurosurgical significance and applications in skull base surgery. Part I focuses on the bony and dural anatomy.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, United States
- Correspondence: Ali Tayebi Meybodi ;
| | - Giancarlo Mignucci-Jiménez
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Michael T. Lawton
- Departments of Neurosurgery and Otolaryngology, Robert Wood Johnson Barnabas Health, Newark, NJ, United States
| | - James K. Liu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Mark C. Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States
| | - Hai Sun
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, United States
- Departments of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
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Meybodi AT, Liang AS, Mokhtari P, Moreira LB, Zhao X, Lawton MT, Preul MC. Nervus intermedius: Microsurgical and anatomic relationships to the cerebellopontine angle neurovascular complex. Surg Neurol Int 2023; 14:37. [PMID: 36895247 PMCID: PMC9990784 DOI: 10.25259/sni_1097_2022] [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: 12/08/2022] [Accepted: 12/28/2022] [Indexed: 02/05/2023] Open
Abstract
Background The nervus intermedius (NI) comprises fibers originating from the trigeminal, superior salivary, and solitary tract nuclei, which join the facial nerve (cranial nerve [CN] VII). Neighboring structures include the vestibulocochlear nerve (CN VIII), the anterior inferior cerebellar artery (AICA), and its branches. Microsurgical procedures at the cerebellopontine angle (CPA) benefit from understanding NI anatomy and relationships, especially for the microsurgical treatment of geniculate neuralgia, where the NI is transected. This study sought to characterize common relationships between the NI rootlets, CN VII, CN VIII, and the meatal loop of AICA at the internal auditory canal (IAC). Methods Seventeen cadaveric heads underwent retrosigmoid craniectomy. Following complete unroofing of the IAC, the NI rootlets were individually exposed to identify their origins and insertion points. The AICA and its meatal loop were traced to assess their relationship with the NI rootlets. Results Thirty-three NIs were identified. The median number of NI rootlets was 4 per NI (interquartile range, 3-5). The rootlets mainly originated from the proximal premeatal segment of CN VIII (81 of 141, 57%) and inserted onto CN VII at the IAC fundus (89 of 141, 63%). When crossing the acoustic-facial bundle, the AICA most frequently passed between the NI and CN VIII (14 of 33, 42%). Five composite patterns of neurovascular relationships were identified regarding NI. Conclusion Although certain anatomical trends can be identified, the NI has a variable relationship with the adjacent neurovascular complex at the IAC. Therefore, anatomical relationships should not be used as the sole method of NI identification during CPA surgery.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Allison S Liang
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - Pooneh Mokhtari
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, United States
| | - Leandro Borba Moreira
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Xiaochun Zhao
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Tayebi Meybodi A, Liu JK. Commentary: Minimally Invasive Occipital Artery to C1-C2 V3 Bypass: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e394-e396. [DOI: 10.1227/ons.0000000000000436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 11/06/2022] Open
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Habibi Z, Meybodi AT, Lo WB, Zanon N. Editorial: Optic pathway glioma: A multidisciplinary entity, posing dilemmas in diagnosis and management. Front Surg 2022; 9:995404. [PMID: 35990103 PMCID: PMC9382243 DOI: 10.3389/fsurg.2022.995404] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 07/19/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Zohreh Habibi
- Children’s Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Correspondance: Zohreh Habibi
| | - Ali Tayebi Meybodi
- New Jersey Medical School, Rutgers, The State University of New Jersey Newark, Newark, NJ, United States
| | - William B. Lo
- Department of Neurosurgery, Birmingham Children’s Hospital, Birmingham, United Kingdom
| | - Nelci Zanon
- Department of Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
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Tayebi Meybodi A, Liu JK. Endoscopic-assisted combined transcrusal anterior petrosal approach for resection of large petroclival meningioma: operative video and nuances of technique. Neurosurgical Focus: Video 2022; 6:V10. [PMID: 36285004 PMCID: PMC9559220 DOI: 10.3171/2022.1.focvid21257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/24/2022] [Indexed: 11/30/2022]
Abstract
In this illustrative video, the authors demonstrate an endoscopic-assisted combined transcrusal anterior petrosal approach for resection of a large petroclival meningioma with significant brainstem compression involving Meckel’s cave. This unique petrosal variant provides increased petroclival exposure that can potentially preserve hearing by combining a transcrusal labyrinthectomy with anterior petrosectomy (Kawase’s approach). The advantages include multidirectional angles of attack to the brainstem and petroclival region without cerebellar retraction. Endoscopic assistance allows expanded visualization into deep surgical corridors. The surgery was performed in a two-stage fashion, and a near-total resection was achieved with cranial nerve and hearing preservation. The operative nuances are demonstrated. The video can be found here: https://stream.cadmore.media/r10.3171/2022.1.FOCVID21257
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurological Surgery, Center for Skull Base and Pituitary Surgery, Rutgers New Jersey Medical School, Newark; and
- Saint Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey
| | - James K. Liu
- Department of Neurological Surgery, Center for Skull Base and Pituitary Surgery, Rutgers New Jersey Medical School, Newark; and
- Saint Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey
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Tayebi Meybodi A, Jyung RW, Liu JK. Retrosigmoid approach for giant cystic vestibular schwannoma: subperineural dissection technique for facial nerve preservation. Neurosurgical Focus: Video 2021; 5:V7. [PMID: 36285246 PMCID: PMC9550012 DOI: 10.3171/2021.7.focvid21128] [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] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/20/2021] [Indexed: 11/24/2022]
Abstract
In this illustrative video, the authors demonstrate retrosigmoid resection of a giant cystic vestibular schwannoma using the subperineural dissection technique to preserve facial nerve function. This thin layer of perineurium arising from the vestibular nerves is used as a protective buffer to shield the facial and cochlear nerves from direct microdissection trauma. A near-total resection was achieved, and the patient had an immediate postoperative House-Brackmann grade I facial nerve function. The operative nuances and pearls of technique for safe cranial nerve and brainstem dissection, as well as the intraoperative decision and technique to leave the least amount of residual adherent tumor, are demonstrated. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21128
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Affiliation(s)
| | - Robert W. Jyung
- Otolaryngology–Head and Neck Surgery,
- Center for Skull Base and Pituitary Surgery, Rutgers University New Jersey Medical School, Newark; Saint Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey
| | - James K. Liu
- Departments of Neurological Surgery and
- Center for Skull Base and Pituitary Surgery, Rutgers University New Jersey Medical School, Newark; Saint Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey
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Agarwalla PK, Meybodi AT, Ward M, Paskhover B. The Vascularized Occipital Fascial Flap (OFF): A Novel Reconstructive Technique for Posterior Fossa Surgery. World Neurosurg 2021; 154:32-38. [PMID: 34224888 DOI: 10.1016/j.wneu.2021.06.122] [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: 03/31/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Posterior fossa surgery is particularly prone to cerebrospinal fluid (CSF) leakage. Several methods have been introduced to address and/or prevent this complication. However, to the best of our knowledge, the use of a vascularized fascial flap based on the occipital artery for the purpose of reconstruction has not been reported. We introduce the occipital fascial flap (OFF) for reconstruction of a craniectomy defect after the retrosigmoid approach. METHODS A 57-year-old woman with a large cerebellar metastasis underwent gross total resection of the mass followed by reconstruction of the craniectomy defect using OFF. RESULTS Postoperative imaging showed flap viability and no CSF leak occurred during follow-up. CONCLUSIONS We report the first use of OFF for reconstruction of a craniectomy defect in a retrosigmoid approach. The vascularized fascial flap in posterior fossa surgery is a potentially helpful technique to reduce the risk of CSF leak in high-risk patients.
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Affiliation(s)
- Pankaj K Agarwalla
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Max Ward
- Department of Neurological Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Boris Paskhover
- Department of Otolaryngology, Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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15
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Tayebi Meybodi A, Gadhyia A, Borba Moreira L, Lawton MT. Coding cerebral bypasses: a proposed nomenclature to better describe bypass constructs and revascularization techniques. J Neurosurg 2021; 136:163-174. [PMID: 34214977 DOI: 10.3171/2020.9.jns202362] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 06/17/2020] [Accepted: 09/24/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Bypass surgery has evolved into a complex surgical art with a variety of donor arteries, recipient arteries, interpositional grafts, anastomoses, and suturing techniques. Although innovation in contemporary bypasses has increased, the literal descriptions of these new bypasses have not kept pace. The existing nomenclature that joins donor and recipient arteries with a hyphen is simplistic, underinformative, and in need of improvement. This article proposes a nomenclature that systematically incorporates anatomical and technical details with alphanumeric abbreviations and is a clear, concise, and practical "code" for bypass surgery. METHODS Detailed descriptions and illustrations of the proposed nomenclature, which consists of abbreviations for donor and recipient arteries, arterial segments, arteriotomies, and sides (left or right), with hyphens and parentheses to denote the arteriotomies joined in the anastomosis and brackets and other symbols for combination bypasses, are presented. The literature was searched for articles describing bypasses, and descriptive nomenclature was categorized as donor and recipient arteries (donor-recipient), donor-recipient with additional details, less detail than donor-recipient, and complete, ambiguous, or descriptive text. RESULTS In 483 publications, most bypass descriptions were categorized as donor-recipient (335, 69%), with superficial temporal artery-middle cerebral artery bypass described most frequently (299, 62%). Ninety-seven articles (20%) used donor-recipient descriptions with additional details, 45 (9%) were categorized as ambiguous, and none contained a complete bypass description. The authors found the proposed nomenclature to be easily applicable to the more complex bypasses reported in the literature. CONCLUSIONS The authors propose a comprehensive nomenclature based on segmental anatomy and additional anastomotic details that allows bypasses to be coded simply, succinctly, and accurately. This alphanumeric shorthand allows greater precision in describing bypasses and clarifying technical details, which may improve reporting in the literature and thus help to advance the field of bypass surgery.
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Affiliation(s)
- Ali Tayebi Meybodi
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.,2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Arjun Gadhyia
- 2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Leandro Borba Moreira
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Michael T Lawton
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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16
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Tayebi Meybodi A, Liu JK. Combined Petrosal Approach for Resection of a Large Trigeminal Schwannoma With Meckel's Cave Involvement-Part II: Microsurgical Approach and Tumor Resection: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E226. [PMID: 33300040 DOI: 10.1093/ons/opaa364] [Citation(s) in RCA: 2] [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: 04/20/2020] [Accepted: 09/06/2020] [Indexed: 11/13/2022] Open
Abstract
This video is the second part of a 2-part video presentation demonstrating the microsurgical technique of a combined petrosal approach for resection of a large trigeminal schwannoma in a 54-yr-old woman involving multiple cranial fossae extending anteriorly into Meckel's cave. The patient presented with long-standing worsening headache and facial tingling and numbness. After discussing the benefits and risks of the surgery as well as the alternative management strategies, the patient decided to proceed with surgery and informed consent was obtained. The surgery was performed in a single stage. The technical nuances of anterior and posterior (retrolabyrinthine) petrosectomy are demonstrated and discussed. Microsurgical resection of the tumor is also demonstrated emphasizing the important steps of dural opening, arachnoid dissection, identification and preservation of cranial nerves, and exploration of Meckel's cave. Use of endoscopic-assistance for visualization of the cerebellopontine angle and neurovascular structures is also demonstrated. Table in video reprinted by permission from Copyright Clearance Center: Springer Nature, Acta Neurochirurgica, Frontotemporal epidural approach to trigeminal neurinomas, Dolenc VV, Copyright 1994.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey; Saint Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey
| | - James K Liu
- Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey; Saint Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey
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17
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Baranoski JF, Koester SW, Przybylowski CJ, Zhao X, Catapano JS, Gandhi S, Tayebi Meybodi A, Cole TS, Lee J, Frisoli FA, Lawton MT, Mascitelli JR. The Glossopharyngo-Cochlear Triangle-Part II: Case Series Highlighting the Clinical Application to High-Riding Posterior Inferior Cerebellar Artery Aneurysms Exposed Through the Extended Retrosigmoid Approach. Oper Neurosurg (Hagerstown) 2021; 20:252-259. [PMID: 33372992 DOI: 10.1093/ons/opaa362] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 02/06/2020] [Accepted: 08/27/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Use of the far lateral transcondylar (FL) approach and vagoaccessory triangle is the standard exposure for clipping most posterior inferior cerebellar artery (PICA) aneurysms. However, a distal PICA origin or high-lying vertebrobasilar junction can position the aneurysm beyond the vagoaccessory triangle, making the conventional FL approach inappropriate. OBJECTIVE To demonstrate the utility of the extended retrosigmoid (eRS) approach and a lateral trajectory through the glossopharyngo-cochlear triangle as the surgical corridor for these cases. METHODS High-riding PICA aneurysms treated by microsurgery were retrospectively reviewed, comparing exposure through the eRS and FL approaches. Clinical, surgical, and outcome measures were evaluated. Distances from the aneurysm neck to the internal auditory canal (IAC), jugular foramen, and foramen magnum were measured. RESULTS Six patients with PICA aneurysms underwent clipping using the eRS approach; 5 had high-riding PICA aneurysms based on measurements from preoperative computed tomography angiography (CTA). Mean distances of the aneurysm neck above the foramen magnum, below the IAC, and above the jugular foramen were 27.0 mm, 3.7 mm, and 8.2 mm, respectively. Distances were all significantly lower versus the comparison group of 9 patients with normal or low-riding PICA aneurysms treated using an FL approach (P < .01). All 6 aneurysms treated using eRS were completely occluded without operative complications. CONCLUSION The eRS approach is an important alternative to the FL approach for high-riding PICA aneurysms, identified as having necks more than 23 mm above the foramen magnum on CTA. The glossopharyngo-cochlear triangle is another important anatomic triangle that facilitates microsurgical dissection.
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Affiliation(s)
- Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Colin J Przybylowski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Xiaochun Zhao
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Sirin Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jonathan Lee
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Fabio A Frisoli
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
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Borba Moreira L, Tayebi Meybodi A, Zhao X, Almefty KK, Lawton MT, Preul MC. Dissection of the Petrosal Presigmoid-Retrolabyrinthine Approach for the Petroclival Region on a Cadaver: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 19:E398-E399. [PMID: 32392291 DOI: 10.1093/ons/opaa117] [Citation(s) in RCA: 2] [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: 08/29/2019] [Accepted: 03/14/2020] [Indexed: 11/13/2022] Open
Abstract
Skull base epidermoid tumors, meningiomas, and schwannomas can be accessed by different techniques depending on the location and size of the lesion. Small lesions located anterior to the internal acoustic meatus (IAM) can be accessed via the subtemporal approach, and lesions located posterior to the IAM can be approached via retrosigmoid craniotomy. However, expansive lesions that are located anterior to the IAM and extend posteriorly toward the lower clivus can be accessed via the petrosal approach. The petrosal approach (presigmoid-retrolabyrinthine) is centered on the petrous ridge of the temporal bone and is mainly performed for intradural lesions located at the clivus and petroclivus junction area. Patients with intact hearing can benefit from this technique, as the labyrinth is untouched and yet the middle and posterior fossa compartments are connected. Additionally, extension of the lesion from the suprasellar area/cavernous sinus to the foramen magnum can be dissected and removed. There are variations of the petrosal approach, such as translabyrinthine, transotic, and transchoclear, with which hearing cannot be preserved, and the "transcrusal" approach, wherein posterior and superior semicircular canals are sacrificed yet hearing preserved. The endolymphatic duct is usually transected and not reapproximated. Neurotology input is always helpful when dealing with inner ear structures. This complex approach demands exhaustive practice with temporal bone dissection in a cadaver laboratory. Although this approach can be extended anteriorly, combination with an anterior petrosal approach permits more rostral exposure. In this video, we demonstrate the stepwise dissection of the posterior petrosal approach only, showing procedure nuances in a cadaver.1-8Used with permission from Barrow Neurological Institute, Phoenix, Arizona.
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Affiliation(s)
- Leandro Borba Moreira
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ali Tayebi Meybodi
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Xiaochun Zhao
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Kaith K Almefty
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark C Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Tayebi Meybodi A, Liu JK. Combined Petrosal Approach for Resection of a Large Trigeminal Schwannoma With Meckel's Cave Involvement-Part I: Anatomic Rationale and Analysis: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E225. [PMID: 33294932 DOI: 10.1093/ons/opaa363] [Citation(s) in RCA: 3] [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] [Received: 04/20/2020] [Accepted: 09/06/2020] [Indexed: 11/14/2022] Open
Abstract
Resection of large trigeminal schwannomas involving both posterior and middle cranial fossae is challenging. The depth of the surgical target in the superomedial corner of the cerebellopontine angle and the petrous apex makes for a difficult lesion to favorably access, expose, and safely resect. Judicious planning of a skull base approach is therefore the most crucial step in successful management of these formidable tumors. When properly chosen, planned, and executed, the combined petrosal approach sets the stage for an optimal exposure of such tumors that involve both posterior and middle cranial fossae. The present video is the first of a 2-part video presentation that explains the anatomic rationale of selecting a combined petrosal approach (anterior petrosectomy and retrolabyrinthine petrosectomy) for the resection of a large trigeminal schwannoma involving the posterior and middle cranial fossae with an extension into Meckel's cave in a 54-yr-old female presenting with 5-yr history of increasing headaches, left-sided face numbness, and disequilibrium. The benefits, risks, and alternatives of the surgical procedure were discussed in detail with the patient and she consented to proceed with surgery. Part I also discusses the important nuances of positioning the patient, as well as planning and execution of the skin incision, including pericranial flap harvesting. Of note, the patient consented to the publication of images obtained from her.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - James K Liu
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
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20
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Zhao X, Tayebi Meybodi A, Naeem K, Belykh E, Labib MA, Baranoski JF, Catapano JS, Mascitelli JR, Preul MC, Lawton MT. The Glossopharyngo-Cochlear Triangle-Part I: Quantitative Anatomic Analysis of High-Riding Posterior Inferior Cerebellar Artery Aneurysms Exposed Through the Extended Retrosigmoid Approach. Oper Neurosurg (Hagerstown) 2021; 20:242-251. [PMID: 33372996 DOI: 10.1093/ons/opaa356] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 02/06/2020] [Accepted: 08/26/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND An extended retrosigmoid approach can offer sufficient space for clip reconstruction of some high-riding posterior inferior cerebellar artery (PICA) aneurysms. OBJECTIVE To quantitatively investigate the glossopharyngo-cochlear triangle (GCT) and anatomic structures within it. METHODS Extended retrosigmoid craniotomies were performed on 10 sides of cadaveric heads, and the GCT was identified in each specimen. The length of the base and the area of the GCT were measured. The depth of the vertebrobasilar system and the abducens nerve to the GCT were measured. The proximal and distal exposable and controllable points on the vertebrobasilar system were identified. Two imaging-based patient selection algorithms are provided using the lengths from those points to the vertebral artery dural entry point and the superoinferior distances from those points to the inferior edge of the foramen magnum. Other factors related to accessibility via the GCT were investigated. RESULTS The mean (standard deviation [SD]) area of the GCT was 45.7 (12.55) mm2. The mean (SD) depth of the abducens nerve was 14.3 (1.42) mm. The mean (SD) superoinferior distances from the foramen magnum to those points were 23.1 (7.39), 24.7 (8.25), 30.0 (9.56), and 32.6 (7.79) mm, respectively. The lower segment of the vertebrobasilar system was more superficial in the setting of a high-lying vertebrobasilar junction (VBJ) than a low-lying VBJ. CONCLUSION We describe the GCT in an extended retrosigmoid approach for high-riding PICA aneurysms and evaluate the spatial relationship of the neurovascular structures within it. Two potential algorithms are offered for preoperative patient selection.
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Affiliation(s)
- Xiaochun Zhao
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Komal Naeem
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mohamed A Labib
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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21
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Mokhtari P, Tayebi Meybodi A, Lawton MT. Learning microvascular anastomosis: Analysis of practice patterns. J Clin Neurosci 2021; 90:212-216. [PMID: 34275552 DOI: 10.1016/j.jocn.2021.06.001] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/25/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Performing a successful microsurgical vascular anastomosis (MVA) is challenging and requires lots of practice. However, the most efficient practice protocol is yet to be found. We aimed to compare and analyze two major practice patterns for fine motor tasks as applied to learning MVA: distributed and mass practice protocols. Ten neurosurgeons with comparable experience in microsurgery (but no experience in vascular anastomosis) were randomized to practice MVA either using a distributed (1 session/day) or a mass practice (6 sessions/day) protocol. A total of 24 sessions of practice and 2 recall test sessions were given. Anastomosis score, time to complete a single stitch and the total time to complete an anastomosis were recorded. Mass practice protocol caused a clear fatigue effect observed toward the end of each mass practice trial block. Statistical comparison using one-way analysis of variance showed significantly higher anastomosis scores and shorter times to place a single stitch as well as to complete the anastomosis in distributed practice group for the last 3 acquisition practice trials, and the 2 recall tests (p < 0.05). The relative advantage of the distributed practice protocol could be attributed to forgetting/spacing effect. Although mass practice protocol resulted in worse performance, it still showed a gradual improvement trend in performance from beginning to the end. Therefore, certain adjustments to a mass practice protocol (such as increasing the number of practice blocks) could potentially lead to an eventual performance level comparable to a distributed protocol. This point is a subject of further investigation.
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Affiliation(s)
- Pooneh Mokhtari
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Ali Tayebi Meybodi
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA; Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Michael T Lawton
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ, USA
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22
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Nisson PL, Meybodi AT, Berger GK, Thompson A, Morshed RA, Lawton MT. A Location-Based Outcome Analysis of the Most Common Microsurgically Clipped Cerebral Aneurysms: A Single-Center Experience. Neurosurg open 2021. [DOI: 10.1093/neuopn/okaa028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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23
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Tayebi Meybodi A, Moreira LB, Zhao X, Belykh E, Lawton MT, Eschbacher JM, Preul MC. Using the Post-Descendens Hypoglossal Nerve in Hypoglossal-Facial Anastomosis: An Anatomic and Histologic Feasibility Study. Oper Neurosurg (Hagerstown) 2020; 19:436-443. [PMID: 31943073 DOI: 10.1093/ons/opz408] [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: 07/18/2019] [Accepted: 11/11/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hypoglossal-facial anastomosis (HFA) is a popular facial reanimation technique. Mobilizing the intratemporal segment of the facial nerve and using the post-descendens hypoglossal nerve (ie, the segment distal to the take-off of descendens hypoglossi) have been proposed to improve results. However, no anatomic study has verified the feasibility of this technique. OBJECTIVE To assess the anatomic feasibility of HFA and the structural compatibility between the 2 nerves when the intratemporal facial and post-descendens hypoglossal nerves are used. METHODS The facial and hypoglossal nerves were exposed bilaterally in 10 sides of 5 cadaveric heads. The feasibility of a side-to-end (ie, partial end-to-end) HFA with partial sectioning of the post-descendens hypoglossal nerve and the mobilized intratemporal facial nerve was assessed. The axonal count and cross-sectional area of the facial and hypoglossal nerves at the point of anastomosis were assessed. RESULTS The HFA was feasible in all specimens with a mean (standard deviation) 9.3 (5.5) mm of extra length on the facial nerve. The axonal counts and cross-sectional areas of the hypoglossal and facial nerves matched well. Considering the reduction in the facial nerve cross-sectional area after paralysis, the post-descendens hypoglossal nerve can provide adequate axonal count and area to accommodate the facial nerve stump. CONCLUSION Using the post-descendens hypoglossal nerve for side-to-end anastomosis with the mobilized intratemporal facial nerve is anatomically feasible and provides adequate axonal count for facial reanimation. When compared with use of the pre-descendens hypoglossal nerve, this technique preserves C1 fibers and has a potential to reduce glottic complications.
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Affiliation(s)
- Ali Tayebi Meybodi
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Leandro Borba Moreira
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Xiaochun Zhao
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Evgenii Belykh
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jennifer M Eschbacher
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark C Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Gandhi S, Mascitelli JR, Cavallo C, Tayebi Meybodi A, Lawton MT. Far Lateral Craniotomy and Occlusion In Situ of a Lateral Medullary Arteriovenous Malformation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2020; 19:E423. [PMID: 32297633 DOI: 10.1093/ons/opaa092] [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: 08/16/2019] [Accepted: 02/14/2020] [Indexed: 11/12/2022] Open
Abstract
Lateral medullary arteriovenous malformations (AVMs) are located in the pia on the lateral medullary surface.1 They are supplied by arterial feeders from the V4 segment of the vertebral artery or posterior inferior cerebellar artery. A 64-yr-old man presented with leg spasms and progressively worsening gait. Angiography demonstrated a lateral medullary AVM. Patient consent was obtained for the surgical treatment of this lesion. Owing to its eloquent location, an occlusion in situ was performed without resection.1,2 This technique relies on the interruption of the arterial blood supply and occlusion of the draining vein to occlude the AVM. Intraoperative neurophysiological monitoring of motor and somatosensory evoked potentials was used, and the elimination of arteriovenous shunt flow was confirmed using indocyanine green videoangiography. Occlusion in situ preserves the flow to the delicate brainstem perforators and is safer than resection in selected cases like this one. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.
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Affiliation(s)
- Sirin Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Justin R Mascitelli
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Patel PD, Talbot C, Meybodi AT, Al-Mufti F, Sun H, Khandelwal P, Nanda A, Roychowdhury S, Gupta G. Cognard Grade IV Tentorial Dural Arteriovenous Fistula Presenting as Trigeminal Neuralgia: Endovascular Management. World Neurosurg 2020; 144:184. [PMID: 32827746 DOI: 10.1016/j.wneu.2020.08.119] [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: 06/16/2020] [Revised: 08/15/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
Abstract
Tentorial dural arteriovenous fistulas have an increased risk of rupture and hemorrhage, and therefore require urgent treatment to occlude the fistula and proximal venous drainage. This is usually accomplished via endovascular treatment. We present a case of a Cognard grade IV dural arteriovenous fistula that presented as trigeminal neuralgia. This video showcases the angiographic vascular composition of the lesion with main feeders coming from the middle meningeal artery and the tentorial artery of Bernasconi and Cassinari. Details, benefits, and risks of the procedure were thoroughly discussed with the patient and consent was obtained prior to the procedure. We performed endovascular Onyx embolization through a distal branch of the right middle meningeal artery. We were able to successfully occlude the lesion using Onyx embolization and the patient had significant improvement of her pretreatment trigeminal neuralgia.
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Affiliation(s)
- Purvee D Patel
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Christopher Talbot
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Hai Sun
- Department of Neurosurgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Priyank Khandelwal
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Anil Nanda
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Sudipta Roychowdhury
- Department of Neurosurgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Gaurav Gupta
- Department of Neurosurgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA.
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Tayebi Meybodi A. Rat Model for Practicing Microsurgical Vascular Anastomosis. J Reconstr Microsurg 2020; 35:e6. [PMID: 32820491 DOI: 10.1055/s-0040-1715645] [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: 10/23/2022]
Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey
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Nisson PL, Ding X, Tayebi Meybodi A, Palsma R, Benet A, Lawton MT. Revascularization of the Posterior Inferior Cerebellar Artery Using the Occipital Artery: A Cadaveric Study Comparing the p3 and p1 Recipient Sites. Oper Neurosurg (Hagerstown) 2020; 19:E122-E129. [PMID: 32107553 DOI: 10.1093/ons/opaa023] [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: 08/29/2019] [Accepted: 01/01/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Revascularization of the posterior inferior cerebellar artery (PICA) is typically performed with the occipital artery (OA) as an extracranial donor. The p3 segment is the most accessible recipient site for OA-PICA bypass at its caudal loop inferior to the cerebellar tonsil, but this site may be absent or hidden due to a high-riding location. OBJECTIVE To test our hypothesis that freeing p1 PICA from its origin, transposing the recipient into a shallower position, and performing OA-p1 PICA bypass with an end-to-end anastomosis would facilitate this bypass. METHODS The OA was harvested, and a far lateral craniotomy was performed in 16 cadaveric specimens. PICA caliber and number of perforators were measured at p1 and p3 segments. OA-p3 PICA end-to-side and OA-p1 PICA end-to-end bypasses were compared. RESULTS OA-p1 PICA bypass with end-to-end anastomosis was performed in 16 specimens; whereas, OA-p3 PICA bypass with end-to-side anastomosis was performed in 11. Mean distance from OA at the occipital groove to the anastomosis site was shorter for p1 than p3 segments (30.2 vs 48.5 mm; P < .001). Median number of perforators on p1 was 1, and on p3, it was 4 (P < .001). CONCLUSION Although most OA-PICA bypasses can be performed using the p3 segment as the recipient site for an end-to-side anastomosis, a more feasible alternative to conventional OA-p3 PICA bypass in cases of high-riding caudal loops or aberrant anatomy is to free the p1 PICA, transpose it away from the lower cranial nerves, and perform an end-to-end OA-p1 PICA bypass instead.
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Affiliation(s)
- Peyton L Nisson
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.,Department of Neurosurgery, Cedar Sinai, Beverly Hills, California
| | - Xinmin Ding
- ShanXi Province People's Hospital, Yinze District, Taiyuan, China
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ryan Palsma
- College of Medicine, University of Arizona, Tucson, Arizona
| | - Arnau Benet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Meybodi AT, Meybodi KT. Letter: Craniometrics and Ventricular Access: A Review of Kocher's, Kaufman's, Paine's, Menovksy's, Tubbs', Keen's, Frazier's, Dandy's, and Sanchez's Points. Oper Neurosurg (Hagerstown) 2020; 19:E104. [PMID: 32348479 DOI: 10.1093/ons/opaa104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurosurgery Rutgers New Jersey Medical School Newark, New Jersey
| | - Keyvan Tayebi Meybodi
- Department of Neurosurgery Children's Hospital Medical Center Tehran University of Medical Science Tehran, Iran
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Zhao X, Tayebi Meybodi A, Labib MA, Gandhi S, Belykh E, Naeem K, Preul MC, Nakaji P, Lawton MT. Contralateral interoptic approach to paraclinoid aneurysms: a patient-selection algorithm based on anatomical investigation and clinical validation. J Neurosurg 2020; 134:1852-1860. [PMID: 32534498 DOI: 10.3171/2020.3.jns193205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 03/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysms that arise on the medial surface of the paraclinoid segment of the internal carotid artery (ICA) are surgically challenging. The contralateral interoptic trajectory, which uses the space between the optic nerves, can partially expose the medial surface of the paraclinoid ICA. In this study, the authors quantitatively measure the area of the medial ICA accessible through the interoptic triangle and propose a potential patient-selection algorithm that is based on preoperative measurements on angiographic imaging. METHODS The contralateral interoptic trajectory was studied on 10 sides of 5 cadaveric heads, through which the medial paraclinoid ICA was identified. The falciform ligament medial to the contralateral optic canal was incised, the contralateral optic nerve was gently elevated, and the medial surface of the paraclinoid ICA was inspected via different viewing angles to obtain maximal exposure. The accessible area on the carotid artery was outlined. The distance from the distal dural ring (DDR) to the proximal and distal borders of this accessible area was measured. The superior and inferior borders were measured using the clockface method relative to a vertical line on the coronal plane. To validate these parameters, preoperative measurements and intraoperative findings were reviewed in 8 clinical cases. RESULTS In the sagittal plane, the mean (SD) distances from the DDR to the proximal and distal ends of the accessible area on the paraclinoid ICA were 2.5 (1.52) mm and 8.4 (2.32) mm, respectively. In the coronal plane, the mean (SD) angles of the superior and inferior ends of the accessible area relative to a vertical line were 21.7° (14.84°) and 130.9° (12.75°), respectively. Six (75%) of 8 clinical cases were consistent with the proposed patient-selection algorithm. CONCLUSIONS The contralateral interoptic approach is a feasible route to access aneurysms that arise from the medial paraclinoid ICA. An aneurysm can be safely clipped via the contralateral interoptic trajectory if 1) both proximal and distal borders of the aneurysm neck are 2.5-8.4 mm distal to the DDR, and 2) at least one border of the aneurysm neck on the coronal clockface is 21.7°-130.9° medial to the vertical line.
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Tayebi Meybodi A, Singla A, Ren Z, Liu S. Concomitant Reversible Cerebral Vasoconstriction and Hyperperfusion Syndromes Following Carotid Endarterectomy. Cureus 2020; 12:e8541. [PMID: 32670678 PMCID: PMC7357340 DOI: 10.7759/cureus.8541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Cerebral hyperperfusion syndrome (CHS) and reversible cerebral vasoconstriction syndrome (RCVS) are two syndromes characterized by disordered vascular autoregulatory mechanisms of brain. These may be seen after carotid endarterectomy (CEA). We present a patient who developed both syndromes after CEA which is a rare occurrence.
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Tayebi Meybodi A, Hendricks BK, Witten AJ, Hartman J, Tomlinson SB, Cohen-Gadol AA. Virtual Exploration of Safe Entry Zones in the Brainstem: Comprehensive Definition and Analysis of the Operative Approach. World Neurosurg 2020; 140:499-508. [PMID: 32474103 DOI: 10.1016/j.wneu.2020.05.207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 03/08/2020] [Accepted: 04/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND A detailed and accurate understanding of the intrinsic brainstem anatomy and the interrelationship between its internal tracts and nuclei and external landmarks is of paramount importance for safe and effective brainstem surgery. Using anatomical models can be an important step in increasing such understanding. In the present study, we have shown the applicability of our developed virtual 3-dimensional (3D) model in depicting the safe entry zones (SEZs) to the brainstem. METHODS Accurate 3D virtual models of brainstem elements were created using high-resolution magnetic resonance imaging and computed tomography to depict the brainstem SEZs. RESULTS All the described SEZs to different parts of the brainstem were successfully depicted using our 3D virtual models. CONCLUSIONS The virtual models provide an immersive experience of brainstem anatomy, allowing users to understand the intricacies of the microdissection that is necessary to appropriately work through the brainstem nuclei and tracts toward a particular target. The models provide an unparalleled learning environment to understand the SEZs into the brainstem that can be used for training and research.
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Affiliation(s)
- Ali Tayebi Meybodi
- The Neurosurgical Atlas, Indianapolis, Indiana, USA; Department of Neurosurgery, Rutgers University Medical School, Newark, New Jersey, USA
| | | | - Andrew J Witten
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Aaron A Cohen-Gadol
- The Neurosurgical Atlas, Indianapolis, Indiana, USA; Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.
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Tayebi Meybodi A, Zhao X, Borba Moreira L, Preul MC, Alhilali LM, Lawton MT. Microsurgical Anatomy of the Meningeal Branch of the Dorsolateral Medullary Plexus. Oper Neurosurg (Hagerstown) 2020; 18:E197-E204. [PMID: 31538202 DOI: 10.1093/ons/opz283] [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: 04/26/2019] [Accepted: 07/10/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Meningeal branches originating from intradural arteries may be involved in several diseases such as meningeal tumors and arteriovenous lesions. These "pial-dural" arterial connections have been described for anterior cerebral, posterior cerebral, and cerebellar arteries. However, to the best of our knowledge, meningeal supply originating from the arterial plexus over the dorsolateral aspect of the medulla oblongata (dorsolateral medullary plexus [DLMP]) has not been described. OBJECTIVE To define the microsurgical anatomy of the meningeal branch of DLMP. METHODS A total of 20 cadaver heads (40 sides) underwent far-lateral craniotomy and the cerebellomedullary cisterns were explored to find the DLMP and any meningeal branches. Additionally, de-identified intraoperative images of 85 patients with vertebral artery (VA)/posterior inferior cerebellar artery aneurysms who had undergone far-lateral craniotomy were studied to find any meningeal branches of DLMP. RESULTS The meningeal branches of DLMP were identified in 4 cadavers/sides. These branches reached the region of jugular tubercle (JT) after crossing the accessory nerve. In 3 specimens, these branches were joined by a small twig from V4-VA before penetrating the dura. DLMP meningeal branches were found in 12 patients of the studied cohort (14%) with similar anatomical features as those found in the cadaveric study. CONCLUSION DLMP may give rise to meningeal branches to the adjacent dura of JT. The actual prevalence of this anatomic variation is difficult to estimate using our data. However, when present, these branches may have important clinical implications, ie, diseases such as dural arteriovenous fistulas, pial arteriovenous malformations (AVMs), and meningeal-based tumors.
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Affiliation(s)
- Ali Tayebi Meybodi
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Xiaochun Zhao
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Mark C Preul
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Lea M Alhilali
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael T Lawton
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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Patel PD, Meybodi AT, Agarwalla P, Jyung RW, Liu JK. Rapid Recovery of Cranial Nerve Deficits After Anterior Petrosal (Kawase) Approach for Medically Refractory Petrous Apicitis. World Neurosurg 2020; 140:122-127. [PMID: 32434021 DOI: 10.1016/j.wneu.2020.05.070] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The mainstay treatment for petrous apicitis (Gradenigo's syndrome) is medical management with antibiotics, steroids, and placement of pressure equalization tubes. The role for surgery is limited as second-line treatment if conservative methods have failed. CASE DESCRIPTION We report 2 cases of medically refractory petrous apicitis presenting with progressive cranial neuropathies who underwent petrous apex resection and debridement via an anterior petrosal (Kawase) approach. Both patients had improvement of their preoperative cranial nerve deficits within 24-48 hours of surgery, that previously did not improve after 2 weeks of medical management. CONCLUSIONS To our knowledge, the use of the Kawase approach for petrous apicitis has not been previously reported. In addition, we postulate that surgical intervention can potentially result in quicker recovery of preexisting cranial nerve deficits in medically refractory petrous apicitis. This raises the potential role of earlier surgical intervention.
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Affiliation(s)
- Purvee D Patel
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Ali Tayebi Meybodi
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Pankaj Agarwalla
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Robert W Jyung
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - James K Liu
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
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Tayebi Meybodi A, Zhao X, Borba Moreira L, Lawton MT, Preul MC. Zygomatic-Meatal Perpendicular Projection Lines: Bony Landmarks for Early Identification of the Temporal Horn of the Lateral Ventricle. World Neurosurg 2020; 138:e591-e596. [PMID: 32165341 DOI: 10.1016/j.wneu.2020.03.004] [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: 02/06/2020] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Localization of the temporal horn of the lateral ventricle (TH) may be required during temporal lobe and ambient cistern surgery. Most available anatomic landmarks for TH localization are based on adjacent cortical landmarks that are inherently variable or subtle. This study aimed to localize the anterior tip of the TH relative to adjacent bony landmarks. METHODS The TH was exposed on 21 sides of 11 cadaveric heads via removal of the middle temporal gyrus. Two lines were defined: (1) a perpendicular line to the zygomatic arch projected from the anterior concavity of the posterior zygomatic root (line A), and (2) a parallel line passing through the anterosuperior corner of the external auditory canal (line B). Sagittal distances from lines A and B to a parallel line passing through the anterior recess of the TH (line H) were measured. RESULTS Mean (standard deviation) distances from lines A and B to line H were 13.3 (2.5) mm and 11.9 (2.2) mm, respectively. Line H was at 53% (8%) of the line A-line B interval measured from line A. The best way to search for the TH was to start approximately 15 mm posterior to line A and progress posteriorly such that a more posteriorly located TH tip would not be missed. CONCLUSIONS The zygomatic-meatal landmark is a reliable tool to localize TH during various approaches. It is independent from the approach trajectory. This landmark may be used as an ancillary tool in conjunction with other cortical landmarks and image guidance.
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Affiliation(s)
- Ali Tayebi Meybodi
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Xiaochun Zhao
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Leandro Borba Moreira
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mark C Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Tayebi Meybodi A, Zhao X, Borba Moreira L, Lawton MT, Lang MJ, Labib M, Preul MC. The Inferior Nuchal Line as a Simple Landmark for Identifying the Vertebral Artery During the Retrosigmoid Approach. Oper Neurosurg (Hagerstown) 2020; 18:302-308. [PMID: 31214695 DOI: 10.1093/ons/opz152] [Citation(s) in RCA: 5] [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: 09/15/2018] [Accepted: 03/04/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The V3 segment of the vertebral artery (V3-VA) is at risk during various approaches to the craniovertebral junction. Several landmarks have been defined to identify V3-VA, but these landmarks are not routinely exposed during a retrosigmoid (RS) approach, where musculocutaneous dissection inferiorly towards the foramen magnum can threaten this arterial segment. OBJECTIVE To find a landmark that will identify the V3-VA during the RS approach, and analyze the inferior nuchal line (INL) as this novel landmark. METHODS The anatomic relationships between the INL and the V3-VA were assessed in 7 cadaveric heads through RS exposure in the lateral position. RESULTS The INL is an L-shaped bony ridge with horizontal (medial) and vertical (lateral) arms, with the vertical arm being more conspicuous in all specimens (INLV). The mean depths of the V3-VA relative to the medial and lateral ends of the INLV were (mean ± standard deviation) 24.9 ± 7.1 mm, and 8.3 ± 3.2 mm, respectively. In all specimens, the V3-VA was located inferior and anterior to the INLV. CONCLUSION The INL provides an important landmark during RS approach that can protect the V3-VA from inadvertent injury or identify it for use in an interpositional bypass. The INLV identifies the region of the suboccipital triangle where the V3-VA is embedded. INLV is routinely seen during the RS approach, making it more relevant than other classic landmarks such as the transverse process of C1, C1 posterior arch, and the atlantomastoid line that are not exposed during the RS approach.
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Affiliation(s)
- Ali Tayebi Meybodi
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Xiaochun Zhao
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Michael T Lawton
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael J Lang
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Mohamed Labib
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Mark C Preul
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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Bot GM, Zhao X, McElenney BK, Tayebi Meybodi A, Belykh E, Lawton MT, Preul MC. Comparative Analysis of Continuous Suturing, Interrupted Suturing, and Cyanoacrylate-Based Lid Techniques for End-to-End Microvascular Anastomosis: Laboratory Investigation. World Neurosurg 2020; 134:465-471. [DOI: 10.1016/j.wneu.2019.11.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 11/08/2019] [Accepted: 11/09/2019] [Indexed: 12/14/2022]
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Abstract
The cerebral venous drainage system in humans has several unique characteristics that set it apart from its arterial counterpart. The intracranial drainage system can be broadly divided into supra- and infratentorial components. The supratentorial venous drainage is further subclassified into superficial and deep systems, each with a unique set of features. A thorough knowledge of the normal and variant venous drainage pathways is important to understand the different pathologic processes involving the venous vasculature, to identify and anticipate the different venous channels encountered during surgery and also to predict the possible sequelae of intentional or inadvertent venous sacrifice during surgery. This chapter summarizes the anatomic and radiologic characteristics of the venous supply of the supratentorial compartment of the brain, reviews its general characteristics, sheds light on the different classifications and nomenclature used for its descriptions, and briefly discusses its embryologic development.
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Affiliation(s)
- Halima Tabani
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Arnau Benet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States.
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Tayebi Meybodi A, Borba Moreira L, Gandhi S, Catapano JC, Preul MC, Lawton MT. Exposure of the V1 Segment of the Vertebral Artery: Stepwise Cadaveric Surgical Simulation. Oper Neurosurg (Hagerstown) 2019; 19:E32-E38. [DOI: 10.1093/ons/opz363] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 09/12/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Surgical exposure of the V1 segment of the vertebral artery (V1-VA) at the lower neck may be necessary to address intravascular (atherosclerotic) and extravascular (external compression by neoplastic or degenerative) pathologies. The adjacent anatomy at the lower cervical region is complex and relatively unfamiliar to neurosurgeons compared to that of upper cervical levels. High-quality cadaveric images simulating the surgical approach to V1-VA are important for learning the relevant anatomy.
OBJECTIVE
To provide a brief stepwise depiction of the exposure of the V1-VA using a cadaveric surgical simulation.
METHODS
A cadaveric surgical simulation was performed on the left side to expose the V1-VA using the retrojugular and interjugular carotid approaches. The important adjacent anatomic structures en route to the V1-VA were identified.
RESULTS
A stepwise photographic demonstration of the surgical exposure of the V1-VA is provided.
CONCLUSION
Exposure of the V1-VA can be challenging and requires a clear anatomic understanding of the relevant anatomy. The present work attempts to facilitate this objective.
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Affiliation(s)
- Ali Tayebi Meybodi
- Division of Neurological Surgery, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Leandro Borba Moreira
- Division of Neurological Surgery, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Sirin Gandhi
- Division of Neurological Surgery, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Joshua C Catapano
- Division of Neurological Surgery, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Mark C Preul
- Division of Neurological Surgery, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael T Lawton
- Division of Neurological Surgery, Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
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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.
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Tayebi Meybodi A, Borba Moreira L, Zhao X, Lawton MT, Preul MC. Transcavernous Approach to the Upper Basilar and Retroclival Area-Cadaveric Surgical Simulation Video: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2019; 17:E251. [PMID: 30888014 DOI: 10.1093/ons/opz031] [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: 09/25/2018] [Accepted: 02/07/2019] [Indexed: 11/14/2022] Open
Abstract
The transcavernous approach (TcA) is an extension of the pterional approach that widens access to the central and lateral skull base regions. Through working between the nerves and vascular structures within the cavernous sinus, the TcA enables enhanced exposure of areas and structures including but not limited to the retrosellar area, Meckel's cave, and the basilar trunk. When the basilar apex and retrosellar regions are targeted, the TcA offers a valuable solution to the problem of the restricted space between the neurovascular structures of the central skull base through opening and widening the 2 major triangles of the cavernous sinus roof: the clinoidal and oculomotor triangles. Mastery of this approach requires careful review of the anatomy and much time spent in the cadaver lab. Although many quantitative studies and illustrative papers exist on the technical nuances of the TcA to the basilar apex region, the TcA is still difficult to understand, learn, and undertake. This cadaveric surgical simulation attempts to facilitate this objective. Of note, we have demonstrated and discussed the specific variant of the TcA that aims to reach the basilar apex area, and this video does not include the full TcA that also involves complete exposure of the lateral aspect of the cavernous sinus and the Meckel's cave.
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Affiliation(s)
- Ali Tayebi Meybodi
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Xiaochun Zhao
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael T Lawton
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Mark C Preul
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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Labib MA, Borba Moreira L, Zhao X, Gandhi S, Cavallo C, Tayebi Meybodi A, Youssef AS, Little AS, Nakaji P, Preul MC, Lawton MT. The side door and front door to the upper retroclival region: a comparative analysis of the open pretemporal and the endoscopic endonasal transcavernous approaches. J Neurosurg 2019:1-13. [PMID: 31703195 DOI: 10.3171/2019.6.jns19964] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 04/05/2019] [Accepted: 06/28/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The pretemporal transcavernous approach (PTA) and the endoscopic endonasal transcavernous approach (EETA) are both used to access the retroclival region. A direct quantitative comparison of both approaches has not been made. The authors compared the technical nuances of, and surgical exposure afforded by, each approach and identified the key elements of the approach selection process. METHODS Fourteen cadaveric specimens underwent either PTA (group A) or EETA with unilateral (group B) followed by bilateral (group C) interdural pituitary gland transposition. The percentage of drilled clivus; length of exposed oculomotor nerve (cranial nerve [CN] III), posterior cerebral artery (PCA), and superior cerebellar artery (SCA); and surgical area of exposure of both cerebral peduncles and the pons for the 3 groups were measured and compared. RESULTS Group A had a significantly lower percentage of drilled area than group B (mean [SD], 35.6% [11.2%] vs 91.3% [4.9%], p < 0.01). In group C, 100% of the upper third of the clivus was drilled in all specimens. Significantly longer segments of the ipsilateral PCA (p < 0.01) and SCA (p < 0.01) were exposed in group A than in group B. There was no significant difference in the length of the ipsilateral CN III exposed among the 3 groups. There was also no significant difference between group A and either group B or group C for the contralateral CN III or PCA exposure. However, longer segments of the contralateral SCA were exposed in group C than in group A (p = 0.02). Furthermore, longer segments of CN III (p < 0.01), PCA (p < 0.01), and SCA (p < 0.01) were exposed in group C than in group B. For brainstem exposure, there was greater exposure of the pons in group C than in group A (mean [SD], 211.4 [19.5] mm2 vs 157.7 [25.3] mm2, p < 0.01) and group B (211.4 [19.5] mm2 vs 153.9 [34.1] mm2, p < 0.01). However, significantly greater exposure of the ipsilateral peduncle was observed in group A (mean [SD], 125.6 [43.1] mm2) than in groups B and C (56.3 [6.0] mm2, p < 0.01). Group C had significantly greater exposure of the contralateral peduncle than group B (p = 0.02). CONCLUSIONS This study is the first to quantitatively identify the advantages and limitations of the PTA and EETA from an anatomical perspective. Understanding these data may help the skull base surgeon design a maximally effective yet minimally invasive approach to individual lesions.
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Affiliation(s)
- Mohamed A Labib
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Leandro Borba Moreira
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Xiaochun Zhao
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Sirin Gandhi
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Claudio Cavallo
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Ali Tayebi Meybodi
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - A Samy Youssef
- 2Department of Neurosurgery, University of Colorado, Denver, Colorado
| | - Andrew S Little
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - 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
| | - Michael T Lawton
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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Tayebi Meybodi A, Lawton MT, Yousef S, Guo X, González Sánchez JJ, Tabani H, García S, Burkhardt JK, Benet A. Anterior clinoidectomy using an extradural and intradural 2-step hybrid technique. J Neurosurg 2019; 130:238-247. [PMID: 29473783 DOI: 10.3171/2017.8.jns171522] [Citation(s) in RCA: 8] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/28/2017] [Indexed: 11/06/2022]
Abstract
In Brief: The authors found a practical intraoperative landmark to localize the optic strut during anterior clinoidectomy and used it as the basis for performing anterior clinoidectomy in two steps: extradural phase and intradural phase. This anatomically based technique can increase the safety of anterior clinoidectomy by providing easily identifiable landmarks and reducing intradural bone drilling, which could put the adjacent neurovauscular structures at risk.
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Affiliation(s)
- Ali Tayebi Meybodi
- 1Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael T Lawton
- 1Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Sonia Yousef
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and
| | - Xiaoming Guo
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and.,3Department of Neurosurgery, First Affiliated Hospital of Chinese PLA General Hospital, Beijing, People's Republic of China
| | | | - Halima Tabani
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and
| | - Sergio García
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and
| | - Jan-Karl Burkhardt
- 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California; and
| | - Arnau Benet
- 1Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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Mascitelli J, Gandhi S, Cavallo C, Baranoski J, Meybodi AT, Lawton MT. Excision and Primary Reanastomosis of the Anterior Inferior Cerebellar Artery for Treatment of a Ruptured Mycotic Aneurysm: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2019; 19:E58-E59. [DOI: 10.1093/ons/opz292] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 07/29/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Anterior inferior cerebellar artery (AICA) aneurysms are rare lesions with a predisposition for distal location and non-saccular morphology.1,2 These aneurysms are less amenable to clipping and may instead require aneurysm trapping with bypass.3 This video reports a novel bypass for a ruptured, fusiform distal AICA aneurysm. A 51-yr-old woman with newly diagnosed acquired immunodeficiency syndrome presented to the hospital with meningitis and experienced an acute neurological decline while admitted. Neuroimaging revealed a fusiform left a2-AICA aneurysm, thought to be mycotic with diffuse subarachnoid and intraventricular hemorrhage (Hunt-Hess Grade-IV). The occipital artery was harvested as an alternative donor in the myocutaneous flap using a hockey-stick incision. An extended retrosigmoid approach exposed the infectious aneurysm. After aneurysm excision, an a2-AICA-a2-AICA end-to-end reanastomosis was performed in between and deep to the vestibulocochlear nerves superiorly and the glossopharyngeal nerve inferiorly. Indocyanine green videoangiography and postoperative angiogram confirmed bypass patency. Postoperatively, she developed epidural and subdural hematomas due to human immunodeficiency virus-associated coagulopathy and/or increased aspirin sensitivity, requiring reoperation. The patient made a complete recovery at late follow-up. AICA reanastomosis is an elegant intracranial-intracranial bypass for treating distal AICA aneurysms. To our knowledge, this is the first report of AICA reanastomosis in the proximal a2-AICA (lateral pontine) segment. This technique has been reported in the literature for distally located aneurysms (a3-AICA).4 Microanastomosis for more medial AICA aneurysms must be performed deep to the lower cranial nerves. OA to a3-AICA bypass is an alternative in cases where primary reanastomosis is not technically feasible. (Published with permission from Barrow Neurological Institute).
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Affiliation(s)
- Justin Mascitelli
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Sirin Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Claudio Cavallo
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Jacob Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
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Rubio RR, Gandhi S, Vigo V, Tabani H, Meybodi AT, Abla AA, Lawton MT, Benet A. An Anatomic Feasibility Study for Revascularization of the Ophthalmic Artery, Part I: Intracanalicular Segment. World Neurosurg 2019; 133:e893-e901. [PMID: 31541753 DOI: 10.1016/j.wneu.2019.08.260] [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: 06/18/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The anatomico-functional complexity of the ophthalmic segment aneurysms is attributable to the presence of critical neurovascular structures in the surgical field. Surgical clipping of the ophthalmic artery (OpA) aneurysms can result in postoperative visual deficit due to the complexity of the aneurysm, vasospasm, or optic nerve manipulation. In this study, we aimed to characterize the feasibility of an intracanalicular OpA (iOpA) revascularization with 2 donor vessels: an intracranial-intracranial (IC-IC) bypass using the anterior temporal artery (ATA) and an extracranial-intracranial (EC-IC) bypass using the superficial temporal artery (STA). We further discuss their potential role in "unclippable" OpA aneurysms. METHODS Twenty cadaveric specimens were used to evaluate the operative exposure of the intradural and intracanalicular OpA segments using an extradural-intradural intracanalicular approach. The arterial caliber and length at the anastomotic sites and required donor artery lengths were measured. The feasibility of the bypass using both donors was assessed. RESULTS The average length of the intradural and intracanalicular segment of the OpA was 9.5 ± 1.6 mm. The mean caliber of the iOpA was 1.5 ± 0.2 mm. The mean ATA length required for an ATA-OpA anastomosis was 26.7 ± 8.9 mm, with a mean caliber of 1.0 ± 0.1 mm. The mean length of STA required for the bypass was 89.9 ± 9.7 mm, with a mean caliber of 1.92 ± 0.4 mm. CONCLUSIONS This study confirms the feasibility of iOpA revascularization using IC-IC and EC-IC bypasses. These techniques could potentially be used for prophylactic or therapeutic neuroprotection from retinal ischemic injury while treating complex OpA aneurysms, infiltrative tumors, or intraoperative arterial injuries.
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Affiliation(s)
- Roberto Rodriguez Rubio
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA.
| | - Sirin Gandhi
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Vera Vigo
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Halima Tabani
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Ali Tayebi Meybodi
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Arnau Benet
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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Zhao X, Belykh E, Przybylowski CJ, Borba Moreira L, Gandhi S, Tayebi Meybodi A, Cavallo C, Valli D, Wicks RT, Nakaji P. Surgical treatment of falcotentorial meningiomas: a retrospective review of a single-institution experience. J Neurosurg 2019; 133:1-12. [PMID: 31374550 DOI: 10.3171/2019.4.jns19208] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 01/23/2019] [Accepted: 04/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Meningiomas at the falcotentorial junction represent a rare subgroup of complex meningiomas. Debate remains regarding the appropriate treatment strategy for and optimal surgical approach to these tumors, and surgical outcomes have not been well described in the literature. The authors reviewed their single-institution experience in the management, approach selection, and outcomes for patients with falcotentorial meningiomas. METHODS From the medical records, the authors identified all patients with falcotentorial meningiomas treated with resection at the Barrow Neurological Institute between January 2007 and October 2017. Perioperative clinical, surgical, and radiographic data were retrospectively collected. For patients who underwent the supracerebellar infratentorial approach, the tentorial angle was defined as the angle between the line joining the nasion with the tuberculum sellae and the tentorium in the midsagittal plane. RESULTS Falcotentorial meningiomas occurred in 0.97% (14/1441) of the patients with meningiomas. Most of the patients (13/14) were female, and the mean patient age was 59.8 ± 11.3 years. Of 17 total surgeries (20 procedures), 11 were single-stage primary surgeries, 3 were two-stage primary surgeries (6 procedures), 2 were reoperations for recurrence, and 1 was a reoperation after surgery had been aborted because of brain edema. Hydrocephalus was present in 5 of 17 cases, 4 of which required additional treatment. Various approaches were used, including the supracerebellar infratentorial (4/17), occipital transtentorial/transfalcine (4/17), anterior interhemispheric transsplenial (3/17), parietal transventricular (1/17), torcular (2/17), and staged supracerebellar infratentorial and occipital transtentorial/transfalcine (3/17) approaches. Of the 17 surgeries, 9 resulted in Simpson grade IV resection, and 3, 1, and 4 surgeries resulted in Simpson grades III, II, and I resection, respectively. The tentorial angle in cases with Simpson grade I resection was significantly smaller than in those with an unfavorable resection grade (43.3° ± 4.67° vs 54.0° ± 3.67°, p = 0.04). Complications occurred in 10 of 22 approaches (17 surgeries) and included visual field defects (6 cases, 2 permanent and 4 transient), hemiparesis (2 cases), hemidysesthesia (1 case), and cerebellar hematoma (1 case). CONCLUSIONS Falcotentorial meningiomas are challenging lesions. A steep tentorial angle is an unfavorable preoperative radiographic factor for achieving maximal resection with the supracerebellar infratentorial approach. Collectively, the study findings show that versatility is required to treat patients with falcotentorial meningiomas and that treatment goals and surgical approach must be individualized to obtain optimal surgical results.
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Affiliation(s)
- Xiaochun Zhao
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Evgenii Belykh
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
- 2Irkutsk State Medical University, Irkutsk, Russia
| | - Colin J Przybylowski
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Leandro Borba Moreira
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Sirin Gandhi
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Ali Tayebi Meybodi
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Claudio Cavallo
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Daniel Valli
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Robert T Wicks
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Peter Nakaji
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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Sun Q, Zhao X, Gandhi S, Tayebi Meybodi A, Belykh E, Valli D, Cavallo C, Borba Moreira L, Nakaji P, Lawton MT, Preul MC. Quantitative analysis of ipsilateral and contralateral supracerebellar infratentorial and occipital transtentorial approaches to the cisternal pulvinar: laboratory anatomical investigation. J Neurosurg 2019; 133:1-10. [PMID: 31374551 DOI: 10.3171/2019.4.jns19351] [Citation(s) in RCA: 5] [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] [Received: 02/07/2019] [Accepted: 04/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The cisternal pulvinar is a challenging location for neurosurgery. Four approaches for reaching the pulvinar without cortical transgression are the ipsilateral supracerebellar infratentorial (iSCIT), contralateral supracerebellar infratentorial (cSCIT), ipsilateral occipital transtentorial (iOCTT), and contralateral occipital transtentorial/falcine (cOCTF) approaches. This study quantitatively compared these approaches in terms of surgical exposure and maneuverability. METHODS Each of the 4 approaches was performed in 4 cadaveric heads (8 specimens in total). A 6-sided anatomical polygonal region was configured over the cisternal pulvinar, defined by 6 reachable anatomical points in different vectors. Multiple polygons were subsequently formed to calculate the areas of exposure. The surgical freedom of each approach was calculated as the maximum allowable working area at the proximal end of a probe, with the distal end fixed at the posterior pole of the pulvinar. Areas of exposure, surgical freedom, and the working distance (surgical depth) of all approaches were compared. RESULTS No significant difference was found among the 4 different approaches with regard to the surgical depth, surgical freedom, or medial exposure area of the pulvinar. In the pairwise comparison, the cSCIT approach provided a significantly larger lateral exposure (39 ± 9.8 mm2) than iSCIT (19 ± 10.3 mm2, p < 0.01), iOCTT (19 ± 8.2 mm2, p < 0.01), and cOCTF (28 ± 7.3 mm2, p = 0.02) approaches. The total exposure area with a cSCIT approach (75 ± 23.1 mm2) was significantly larger than with iOCTT (43 ± 16.4 mm2, p < 0.01) and iSCIT (40 ± 20.2 mm2, p = 0.01) approaches (pairwise, p ≤ 0.01). CONCLUSIONS The cSCIT approach is preferable among the 4 compared approaches, demonstrating better exposure to the cisternal pulvinar than ipsilateral approaches and a larger lateral exposure than the cOCTF approach. Both contralateral approaches described (cSCIT and cOCTF) provided enhanced lateral exposure to the pulvinar, while the cOCTF provided a larger exposure to the lateral portion of the pulvinar than the iOCTT. Medial exposure and maneuverability did not differ among the approaches. A short tentorium may negatively impact an ipsilateral approach because the cingulate isthmus and parahippocampal gyrus tend to protrude, in which case they can obstruct access to the cisternal pulvinar ipsilaterally.
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Affiliation(s)
- Qing Sun
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
- 2Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China; and
| | - Xiaochun Zhao
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Sirin Gandhi
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ali Tayebi Meybodi
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Evgenii Belykh
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
- 3Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Daniel Valli
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Claudio Cavallo
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Leandro Borba Moreira
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Peter Nakaji
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark C Preul
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Lau R, Rodriguez Rubio R, Martino J, Sanmillán JL, Benet A, Tayebi Meybodi A, Gandhi S, Kournoutas I, Gabarrós A. Endoscopic Transanterior Middle Temporal Approach to the Atrium—An Anatomical Feasibility Study. World Neurosurg 2019; 128:e98-e106. [DOI: 10.1016/j.wneu.2019.04.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 11/27/2022]
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Tayebi Meybodi A, Moreira LB, Lawton MT, Preul MC. Exposure of the External Carotid Artery Through the Posterior Neck Triangle, Cadaveric Surgical Simulation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2019; 17:E65. [PMID: 30566681 DOI: 10.1093/ons/opy373] [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: 07/05/2018] [Accepted: 11/08/2018] [Indexed: 11/12/2022] Open
Abstract
The external carotid artery (ECA) is a robust extracranial donor used for high-flow cerebrovascular bypass procedures. It is usually exposed through the anterior triangle of the neck and may be used to revascularize recipients in the anterior or upper posterior cerebral circulations. However, when a high-flow bypass to the posterior circulation is indicated, oftentimes the patient needs to be put in the prone position (or variants thereof). In such situations, accessing the ECA through the anterior triangle of the neck can be challenging. Therefore, using a technique that enables the surgeon to expose the ECA through a posterior approach could be helpful.1 Although we have not yet encountered a case requiring this type of exposure and bypass, this cadaveric surgical simulation video demonstrates the surgical technique of exposing the ECA through the posterior triangle of the neck (as a cadaveric video, no patient consent was necessary). Briefly, this technique involves an inferolateral extension of the muscular stage of the far-lateral approach and exposing the ECA through a plane developed between the parotid gland and the posterior belly of the digastric muscle. The technical details of this technique are described. Also, relevant anatomic information regarding the safety measures taken to protect adjacent neurovascular structures are discussed.
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Affiliation(s)
- Ali Tayebi Meybodi
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Michael T Lawton
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Mark C Preul
- Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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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.
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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.
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Gandhi S, Tayebi Meybodi A, Belykh E, Cavallo C, Zhao X, Syed MP, Borba Moreira L, Lawton MT, Nakaji P, Preul MC. Survival Outcomes Among Patients With High-Grade Glioma Treated With 5-Aminolevulinic Acid-Guided Surgery: A Systematic Review and Meta-Analysis. Front Oncol 2019; 9:620. [PMID: 31380272 PMCID: PMC6652805 DOI: 10.3389/fonc.2019.00620] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [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: 04/15/2019] [Accepted: 06/24/2019] [Indexed: 01/08/2023] Open
Abstract
Background: High-grade glioma (HGG) is associated with a dismal prognosis despite significant advances in adjuvant therapies, including chemotherapy, immunotherapy, and radiotherapy. Extent of resection continues to be the most important independent prognosticator of survival. This underlines the significance of increasing gross total resection (GTR) rates by using adjunctive intraoperative modalities to maximize resection with minimal neurological morbidity. 5-aminolevulinic acid (5-ALA) is the only US Food and Drug Administration–approved intraoperative optical agent used for fluorescence-guided surgical resection of gliomas. Despite several studies on the impact of intra-operative 5-ALA use on the extent of HGG resection, a clear picture of how such usage affects patient survival is still unavailable. Methods: A systematic review was conducted of all relevant studies assessing the GTR rate and survival outcomes [overall survival (OS) and progression-free survival (PFS)] in HGG. A meta-analysis of eligible studies was performed to assess the influence of 5-ALA-guided resection on improving GTR, OS, and PFS. GTR was defined as >95% resection. Results: Of 23 eligible studies, 19 reporting GTR rates were included in the meta-analysis. The pooled cohort had 998 patients with HGG, including 796 with newly diagnosed cases. The pooled GTR rate among patients with 5-ALA–guided resection was 76.8% (95% confidence interval, 69.1–82.9%). A comparative subgroup analysis of 5-ALA–guided vs. conventional surgery (controlling for within-study covariates) showed a 26% higher GTR rate in the 5-ALA subgroup (odds ratio, 3.8; P < 0.001). There were 11 studies eligible for survival outcome analysis, 4 of which reported PFS. The pooled mean difference in OS and PFS was 3 and 1 months, respectively, favoring 5-ALA vs. control (P < 0.001). Conclusions: This meta-analysis shows a significant increase in GTR rate with 5-ALA–guided surgical resection, with a higher weighted GTR rate (~76%) than the pivotal phase III study (~65%). Pooled analysis showed a small yet significant increase in survival measures associated with the use of 5-ALA. Despite the statistically significant results, the low level of evidence and heterogeneity across these studies make it difficult to conclusively report an independent association between 5-ALA use and survival outcomes in HGG. Additional randomized control studies are required to delineate the role of 5-ALA in survival outcomes in HGG.
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Affiliation(s)
- Sirin Gandhi
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Evgenii Belykh
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States.,Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Claudio Cavallo
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Xiaochun Zhao
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Masood Pasha Syed
- Department of Medicine, Saint Vincent Hospital, Worcester, MA, United States
| | - Leandro Borba Moreira
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Michael T Lawton
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Peter Nakaji
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Mark C Preul
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, United States
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