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Wang H, Hu S, Huang ZN, Ma Y, Yao G, Chen K, Dou N, Xia L, Li S, Zhong J. Riveting technique in percutaneous balloon compression for trigeminal neuralgia remedy. Clin Neurol Neurosurg 2024; 240:108245. [PMID: 38518629 DOI: 10.1016/j.clineuro.2024.108245] [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: 01/18/2024] [Revised: 02/18/2024] [Accepted: 03/13/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND The percutaneous balloon compression (PBC) is a safe and simple treatment for trigeminal neuralgia. It works by compressing the Gasserian ganglion to block pain signals from the trigeminal nerve. To ensure effectiveness, it is important to focus the compression on the lower part of the balloon. OBJECTIVE To validate the efficacy of a riveting technique, specifically pulling an inflated balloon, in order to apply enhanced compression on the ganglion. METHODS To compare this novel technique with the conventional approach, a retrospective investigation was conducted on consecutive PBCs performed in our department between 2019 and 2022. For postoperative outcome assessment, efficacy was defined as achieving a VAS score of 0 or an improvement exceeding 5 points. Postoperative numbness was graded as none, mild, or severe based on its impact on daily life and tolerance level. RESULTS Excluding cases with missed follow-up, a total of 179 participants were included in the study, and their follow-up period ranged up to 40 months. Postoperatively, symptomatic remission was achieved by 98.1% (52/53) of patients in the riveting technique group compared to 87.3% (110/126) in the conventional group (P<0.05). At the last follow-up period, with recurrence observed over time, the long-term efficacy of riveting and conventional groups were 94.3% and 74.6%, respectively (P<0.05). The majority of cases in both groups experienced ipsilateral facial numbness immediately following PBC, which appeared to diminish after 3 months in both groups without significant difference between them (P>0.05).
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Affiliation(s)
- Haolin Wang
- Dept. Neurosurgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - ShaoZhen Hu
- Dept. Neurosurgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zheng Nan Huang
- Dept. Neurosurgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - YuJie Ma
- Dept. Neurosurgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ge Yao
- Dept. Neurosurgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Dept. Neurology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Kui Chen
- Dept. Neurosurgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ningning Dou
- Dept. Neurosurgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lei Xia
- Dept. Neurosurgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shiting Li
- Dept. Neurosurgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jun Zhong
- Dept. Neurosurgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
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Corvino S, Kassam A, Piazza A, Corrivetti F, Spiriev T, Colamaria A, Cirrottola G, Cavaliere C, Esposito F, Cavallo LM, Iaconetta G, de Notaris M. Open-door extended endoscopic transorbital technique to the paramedian anterior and middle cranial fossae: technical notes, anatomomorphometric quantitative analysis, and illustrative case. Neurosurg Focus 2024; 56:E7. [PMID: 38560942 DOI: 10.3171/2024.1.focus23838] [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: 11/14/2023] [Accepted: 01/30/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE The superior eyelid endoscopic transorbital approach (SETOA) provides a direct and short minimally invasive route to the anterior and middle skull base. Nevertheless, it uses a narrow corridor that limits its angles of attack. The aim of this study was to evaluate the feasibility and potential benefits of an "extended" conservative variant of the "standard" endoscopic transorbital approach-termed "open-door"-to enhance the exposure of lesions affecting the paramedian aspect of the anterior and middle cranial fossae. METHODS First, the authors described the technical nuances of the open-door extended transorbital approach (ODETA). Next, they documented its morphometric advantages over standard SETOA. Finally, they provided a clinical-anatomical application to demonstrate enhanced exposure and better angles of attack to treat lesions occupying the paramedian anterior and middle cranial fossae. Five adult cadaveric specimens (10 sides) initially underwent standard SETOA and then extended open-door SETOA (ODETA to the paramedian anterior and middle fossae). The adjunct of hinge-orbitotomy, through three surgical steps and straddling the frontozygomatic suture, converted conventional SETOA to its extended open-door variant. CT scans were performed before dissection and uploaded to the neuronavigation system for quantitative analysis. The angles of attack on the axial plane that addressed four key landmarks, namely the tip of the anterior clinoid process (ACP), foramen rotundum (FR), foramen ovale (FO), and trigeminal impression (TI), were calculated for both operative techniques and compared. RESULTS Hinge-orbitotomy of the extended open-door SETOA resulted in several surgical, functional, and esthetic advantages: it provided wider axial angles of attack for each of the target points, with a gain angle of 26.68° ± 1.31° for addressing the ACP (p < 0.001), 29.50° ± 2.46° for addressing the FR (p < 0.001), 19.86° ± 1.98° for addressing the FO (p < 0.001), and 17.44° ± 2.21° for addressing the lateral aspect of the TI (p < 0.001), while hiding the skin scar, avoiding temporalis muscle dissection, preserving flap vascularization, and decreasing the rate of bone infection and degree of orbital content retraction. CONCLUSIONS The extended open-door technique may be specifically suited for selected patients affected by paramedian anterior and middle fossae lesions, with prevalent anteromedial extension toward the anterior clinoid, the foremost compartment of the cavernous sinus and FR and not completely controlled with the pure endoscopic transorbital approach.
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Affiliation(s)
- Sergio Corvino
- 1Department of Neuroscience and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli "Federico II," Naples, Italy
- 2Department of Neuroscience and Reproductive and Odontostomatological Sciences, PhD Program in Neuroscience, Università degli Studi di Napoli "Federico II," Naples, Italy
- 3Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, Italy
| | - Amin Kassam
- 4Department of Neurosciences, Intent Medical Group, Northshore University Neurosciences Institute, Arlington Heights, Illinois
| | - Amedeo Piazza
- 3Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, Italy
- 5Department of Neurosurgery, "Sapienza" University of Rome, Italy
| | - Francesco Corrivetti
- 3Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, Italy
- 6Department of Neurosurgery, San Luca Hospital, Vallo della Lucania, Salerno, Italy
| | - Toma Spiriev
- 7Department of Neurosurgery, Acibadem City Clinic University Hospital Tokuda, Sofia, Bulgaria
| | | | | | | | - Felice Esposito
- 1Department of Neuroscience and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli "Federico II," Naples, Italy
| | - Luigi Maria Cavallo
- 1Department of Neuroscience and Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Università degli Studi di Napoli "Federico II," Naples, Italy
| | - Giorgio Iaconetta
- 10Neurosurgical Clinic A.O.U. "San Giovanni di Dio e Ruggi d'Aragona," Salerno, Italy
| | - Matteo de Notaris
- 3Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, Italy
- 10Neurosurgical Clinic A.O.U. "San Giovanni di Dio e Ruggi d'Aragona," Salerno, Italy
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Zhang F, Ni Y, Luo G, Zhang Y, Lin J. Independent association of the Meckel's cave with trigeminal neuralgia and development of a screening tool. Eur J Radiol 2024; 171:111272. [PMID: 38154423 DOI: 10.1016/j.ejrad.2023.111272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 11/13/2023] [Accepted: 12/14/2023] [Indexed: 12/30/2023]
Abstract
PURPOSE To 1) investigate the association of the properties of the Meckel's cave (MC) with TN occurrence (i.e., affected vs. unaffected nerves) and whether such association was independent of neurovascular contact (NVC); and 2) develop an objective screening tool for TN. MATERIALS AND METHODS Two hundred and nineteen trigeminal nerves were included. (The severity of) NVC was identified for individual nerve, and a set of 107 radiomic features were extracted to characterize various properties of each MC. Both procedures were primarily based on magnetic resonance imaging sequences. A radiomic score (Rad-score) was constructed for each MC to integrate the features associated with TN occurrence. Independent t-test and logistic regression were conducted to assess the association and develop the screening tool mentioned above. RESULTS Twelve features were selected to build the Rad-score, with the Inverse Difference Moment Normalized (IDMN) having the greatest weight. The Rad-score was significantly (p ≤ 0.05) higher in the affected compared to the unaffected nerves, irrespective of NVC. The Rad-score and NVC were incorporated in the regression model/screening tool, which demonstrated an acceptable discriminating ability (C-statistic = 0.84). CONCLUSION This study has identified a potential association of the properties/features of the MC with TN occurrence, probably involving the demyelination and axonal injury of the trigeminal ganglion within the MC as suggested by the IDMN. Such association may be independent of NVC. This finding may provide new insight into the etiology and/or pathophysiology of TN. The screening tool, which demonstrated an acceptable discriminating ability, may contribute to an improvement in its diagnosis.
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Affiliation(s)
- Fang Zhang
- Department of Neurosurgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Yang Ni
- Department of Neurosurgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Guoxuan Luo
- Department of Neurosurgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Yong Zhang
- Department of Neurosurgery, Guangdong Second Provincial General Hospital, Guangzhou, China; The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China.
| | - Jinzhi Lin
- Department of Neurosurgery, Guangdong Second Provincial General Hospital, Guangzhou, China.
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Li S, Liao C, Wu Y, Yang X, Zhang W. Association between morphological characteristics of Meckel's cave and outcomes after percutaneous balloon compression for primary trigeminal neuralgia. Neurosurg Rev 2023; 46:307. [PMID: 37985480 DOI: 10.1007/s10143-023-02221-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023]
Affiliation(s)
- Shuo Li
- Department of Neurosurgery, Shanghai Ninth People's Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Huangpu District, No.639, Zhizaoju Road, Shanghai, China
| | - Chenlong Liao
- Department of Neurosurgery, Shanghai Ninth People's Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Huangpu District, No.639, Zhizaoju Road, Shanghai, China
| | - Yiwei Wu
- Department of Neurosurgery, Shanghai Ninth People's Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Huangpu District, No.639, Zhizaoju Road, Shanghai, China
| | - Xiaosheng Yang
- Department of Neurosurgery, Shanghai Ninth People's Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Huangpu District, No.639, Zhizaoju Road, Shanghai, China.
| | - Wenchuan Zhang
- Department of Neurosurgery, Shanghai Ninth People's Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Huangpu District, No.639, Zhizaoju Road, Shanghai, China.
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Zanin L, Agosti E, Ebner F, de Maria L, Belotti F, Buffoli B, Rezzani R, Hirt B, Ravanelli M, Ius T, Zeppieri M, Tatagiba MS, Fontanella MM, Doglietto F. Quantitative Anatomical Comparison of Surgical Approaches to Meckel's Cave. J Clin Med 2023; 12:6847. [PMID: 37959312 PMCID: PMC10648058 DOI: 10.3390/jcm12216847] [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: 10/08/2023] [Revised: 10/27/2023] [Accepted: 10/28/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Meckel's cave is a challenging surgical target due to its deep location and proximity to vital neurovascular structures. Surgeons have developed various microsurgical transcranial approaches (MTAs) to access it, but there is no consensus on the best method. Newer endoscopic approaches have also emerged. This study seeks to quantitatively compare these surgical approaches to Meckel's cave, offering insights into surgical volumes and exposure areas. METHODS Fifteen surgical approaches were performed bilaterally in six specimens, including the pterional approach (PTA), fronto-temporal-orbito-zygomatic approach (FTOZA), subtemporal approach (STA), Kawase approach (KWA), retrosigmoid approach (RSA), retrosigmoid approach with suprameatal extension (RSAS), endoscopic endonasal transpterygoid approach (EETPA), inferolateral transorbital approach (ILTEA) and superior eyelid approach (SEYA). All the MTAs were performed both with 10 mm and 15 mm of brain retraction, to consider different percentages of surface exposure. A dedicated navigation system was used to quantify the surgical working volumes and exposure of different areas of Meckel's cave (ApproachViewer, part of GTx-Eyes II, University Health Network, Toronto, Canada). Microsurgical transcranial approaches were quantified with two different degrees of brain retraction (10 mm and 15 mm). Statistical analysis was performed using a mixed linear model with bootstrap resampling. RESULTS The RSAS with 15 mm of retraction offered the maximum exposure of the trigeminal stem (TS). If compared to the KWA, the RSA exposed more of the TS (69% vs. 46%; p = 0.01). The EETPA and ILTEA exposed the Gasserian ganglion (GG) mainly in the anteromedial portion, but with a significant 20% gain in exposure provided by the EETPA compared to ILTEA (42% vs. 22%; p = 0.06). The STA with 15 mm of retraction offered the maximum exposure of the GG, with a significant gain in exposure compared to the STA with 10 mm of retraction (50% vs. 35%; p = 0.03). The medial part of the three trigeminal branches was mainly exposed by the EETPA, particularly for the ophthalmic (66%) and maxillary (83%) nerves. The EETPA offered the maximum exposure of the medial part of the mandibular nerve, with a significant gain in exposure compared to the ILTEA (42% vs. 11%; p = 0.01) and the SEY (42% vs. 2%; p = 0.01). The FTOZA offered the maximum exposure of the lateral part of the ophthalmic nerve, with a significant gain of 67% (p = 0.03) and 48% (p = 0.04) in exposure compared to the PTA and STA, respectively. The STA with 15 mm of retraction offered the maximum exposure of the lateral part of the maxillary nerve, with a significant gain in exposure compared to the STA with 10 mm of retraction (58% vs. 45%; p = 0.04). The STA with 15 mm of retraction provided a significant exposure gain of 23% for the lateral part of the mandibular nerve compared to FTOZA with 15 mm of retraction (p = 0.03). CONCLUSIONS The endoscopic approaches, through the endonasal and transorbital routes, can provide adequate exposure of Meckel's cave, especially for its more medial portions, bypassing the impediment of major neurovascular structures and significant brain retraction. As far as the most lateral portion of Meckel's cave, MTA approaches still seem to be the gold standard in obtaining optimal exposure and adequate surgical volumes.
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Affiliation(s)
- Luca Zanin
- Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy (E.A.)
| | - Edoardo Agosti
- Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy (E.A.)
| | - Florian Ebner
- Department of Neurological Surgery, Eberhard-Karls University, Tübingen University Hospital, D-72076 Tübingen, Germany
| | - Lucio de Maria
- Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy (E.A.)
| | - Francesco Belotti
- Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy (E.A.)
| | - Barbara Buffoli
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy
| | - Rita Rezzani
- Section of Anatomy and Physiopathology, Department of Clinical and Experimental Sciences, University of Brescia, 25123 Brescia, Italy
| | - Bernard Hirt
- Department of Clinical Anatomy, Eberhard-Karls-University, Tübingen University Hospital, D-72076 Tübingen, Germany
| | - Marco Ravanelli
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy
| | - Tamara Ius
- Neurosurgery Unit, Head-Neck and NeuroScience Department, University Hospital of Udine, p.le S. Maria della Misericordia 15, 33100 Udine, Italy
| | - Marco Zeppieri
- Department of Ophthalmology, University Hospital of Udine, p.le S. Maria della Misericordia 15, 33100 Udine, Italy
| | - Marcos Soares Tatagiba
- Department of Neurological Surgery, Eberhard-Karls University, Tübingen University Hospital, D-72076 Tübingen, Germany
| | - Marco Maria Fontanella
- Neurosurgery Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy (E.A.)
| | - Francesco Doglietto
- Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
- Neurosurgery, Università Cattolica del Sacro Cuore, 20123 Rome, Italy
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Chen P, Yan C, Xie T, Li C, Liu T, Yang Q, Liu S, Wu S, Yeh Y, Zhang X. Endoscopic far-lateral supracerebellar infratentorial approach for resection of dumbbell-shaped trigeminal schwannoma: surgical techniques and preliminary results. Acta Neurochir (Wien) 2023; 165:2913-2921. [PMID: 37523075 DOI: 10.1007/s00701-023-05725-0] [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: 04/11/2023] [Accepted: 07/07/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Trigeminal schwannomas (TSs) are mostly benign tumors. However, dumbbell-shaped TSs are most challenging for surgeons and pose a high surgical risk. OBJECTIVE We describe the technique of the purely endoscopic far-lateral supracerebellar infratentorial approach (EFL-SCITA) for removing dumbbell-shaped TSs and further discuss the feasibility of this approach and our experience. METHODS EFL-SCITA was performed for resection of 5 TSs between January 2020 and March 2023. The entire procedure was performed endoscopically with the goal of total tumor resection. During the operation, the tumor was exposed in close proximity and multiple angles under the endoscope, and the peri-tumor nerves were carefully identified and protected, especially the normal trigeminal fiber bundles around the tumor. RESULTS All the tumors of 5 patients involved the middle and posterior cranial fossa, of which total removal was achieved in 2 patients and near-total removal in 3 patients. The most common preoperative symptoms were relieved after surgery. Two patients had postoperative mild facial paralysis (House-Brackmann grade II), and 1 patient had abducens palsy; both recovered during the follow-up period. Two patients experienced new postoperative facial hypesthesia, and 1 experienced mastication weakness, which did not recover. There was no tumor recurrence or residual tumor growth during the follow-up period in any of the patients. CONCLUSION EFL-SCITA is a new and effective alternative for the surgical treatment of TSs. For dumbbell-shaped TSs, this approach provides sufficient surgical field exposure and freedom of operation.
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Affiliation(s)
- Pin Chen
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chaolong Yan
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Xie
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Shanghai Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chen Li
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tengfei Liu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qiaoqiao Yang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shuang Liu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Silin Wu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuyang Yeh
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaobiao Zhang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China.
- Cancer Center, Shanghai Zhongshan Hospital, Fudan University, Shanghai, China.
- Digital Medical Research Center, Fudan University, Shanghai, China.
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Corvino S, Armocida D, Offi M, Pennisi G, Burattini B, Mondragon AV, Esposito F, Cavallo LM, de Notaris M. The anterolateral triangle as window on the foramen lacerum from transorbital corridor: anatomical study and technical nuances. Acta Neurochir (Wien) 2023; 165:2407-2419. [PMID: 37479917 PMCID: PMC10477108 DOI: 10.1007/s00701-023-05704-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/25/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE Neurosurgical indications for the superior eyelid transorbital endoscopic approach (SETOA) are rapidly expanding over the last years. Nevertheless, as any new technique, a detailed knowledge of the anatomy of the surgical target area, the operative corridor, and the specific surgical landmark from this different perspective is required for a safest and successful surgery. Therefore, the aim of this study is to provide, through anatomical dissections, a detailed investigation of the surgical anatomy revealed by SETOA via anterolateral triangle of the middle cranial fossa. We also sought to define the relevant surgical landmarks of this operative corridor. METHODS Eight embalmed and injected adult cadaveric specimens (16 sides) underwent dissection and exposure of the cavernous sinus and middle cranial fossa via superior eyelid endoscopic transorbital approach. The anterolateral triangle was opened and its content exposed. An extended endoscopic endonasal trans-clival approach (EEEA) with exposure of the cavernous sinus content and skeletonization of the paraclival and parasellar segments of the internal carotid artery (ICA) was also performed, and the anterolateral triangle was exposed. Measurements of the surface area of this triangle from both surgical corridors were calculated in three head specimens using coordinates of its borders under image-guide navigation. RESULTS The drilling of the anterolateral triangle via SETOA unfolds a space that can be divided by the course of the vidian nerve into two windows, a wider "supravidian" and a narrower "infravidian," which reveal different anatomical corridors: a "medial supravidian" and a "lateral supravidian," divided by the lacerum segment of the ICA, leading to the lower clivus, and to the medial aspect of the Meckel's cave and terminal part of the horizontal petrous ICA, respectively. The infravidian corridor leads medially into the sphenoid sinus. The arithmetic means of the accessible surface area of the anterolateral triangle were 45.48 ± 3.31 and 42.32 ± 2.17 mm2 through transorbital approach and endonasal approach, respectively. CONCLUSION SETOA can be considered a minimally invasive route complementary to the extended endoscopic endonasal approach to the anteromedial aspect of the Meckel's cave and the foramen lacerum. The lateral loop of the trigeminal nerve represents a reliable surgical landmark to localize the lacerum segment of the ICA from this corridor. Nevertheless, as any new technique, a learning curve is needed, and the clinical feasibility should be proven.
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Affiliation(s)
- Sergio Corvino
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, 80131, Naples, Italy.
- PhD Program in Neuroscience, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, 80131, Naples, Italy.
| | - Daniele Armocida
- Neurosurgery Division, Human Neurosciences Department, "Sapienza" University, 00185, Rome, Italy
| | - Martina Offi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy - Division of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Giovanni Pennisi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy - Division of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Benedetta Burattini
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy - Division of Neurosurgery, Catholic University of Rome, Rome, Italy
| | | | - Felice Esposito
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, 80131, Naples, Italy
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neuroscience and Reproductive and Odontostomatological Sciences, Università Degli Studi Di Napoli Federico II, 80131, Naples, Italy
| | - Matteo de Notaris
- Department of Neuroscience, Neurosurgery Operative Unit, "San Pio" Hospital, 82100, Benevento, Italy
- Laboratory of Neuroanatomy, EBRIS Foundation, European Biomedical Research Institute of Salerno, Salerno, Italy
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Cheng R, Wang T, Cai Y, Chai S, Shen L, Xu D, Yang J, Yue C, Pu J, Xiong N. The Consistency Between the Preoperative 3D-Reconstructed Meckel's Cave and the Intraoperative Balloon Results in Percutaneous Balloon Compression. J Pain Res 2023; 16:2929-2937. [PMID: 37664484 PMCID: PMC10473426 DOI: 10.2147/jpr.s420283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/17/2023] [Indexed: 09/05/2023] Open
Abstract
Objective To predict the volume and shape of the balloon before PBC by reconstructing the Meckel's cave (MC) and establishing a volumetric measurement model, supporting preoperative preparation and intraoperative decisions. Methods The clinical data of 31 patients with good therapeutic effects who underwent PBC are retrospectively collected, including preoperative MRI, the volume of contrast agent injected into the balloon, and intraoperative lateral X-ray images. The MC on the affected side of the 31 patients is reconstructed based on MRI using 3D Slicer, while the volume of the MC is calculated to compare with the volume of contrast agent. The width (W) and length (L) of the model of the MC in lateral view are measured and used to classify the shape of the MC based on W/L. The consistency between the W/L of the model of the MC and the W/L of the intraoperative balloon is evaluated. Results For volume, the mean value of the models of the MC (V1) in 31 patients is 399.77±155.13 mm³, while the mean value of the contrast agent injected during PBC (V2) is 539.03±111.93 mm³. The formula obtained by linear regression is V2= 392.1 + 0.3676×V1. Based on the value of W/L, the shape of the MC is classified into thin "pear" in 5 patients (16.13%), standard "pear" in 22 patients (70.97%), and square "pear" in 4 patients (12.90%). There is no significant difference in W/L between the models of the MC and the intraoperative balloons in 31 patients (P=0.221). Conclusion In 31 patients with good efficacy, it is verified that the prediction of the MC before PBC by 3D Slicer is consistent with the actual situation of the intraoperative balloon. This method can provide certain basis for preoperative preparation and intraoperative judgment.
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Affiliation(s)
- Runqi Cheng
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, People’s Republic of China
| | - Tiansheng Wang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, People’s Republic of China
| | - Yuankun Cai
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, People’s Republic of China
| | - Songshan Chai
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, People’s Republic of China
| | - Lei Shen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, People’s Republic of China
| | - Dongyuan Xu
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, People’s Republic of China
| | - Jingyi Yang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, People’s Republic of China
| | - Chuqiao Yue
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, People’s Republic of China
| | - Jianzhang Pu
- Department of Neurosurgery, Beijing Shunyi District Hospital, Shunyi Teaching Hospital of Capital Medical University, Beijing, People’s Republic of China
| | - Nanxiang Xiong
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, People’s Republic of China
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9
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Le Petit L, Roblot P, Durouchoux A, Kerdiles G, Liguoro D, Jecko V. How to understand an enlarged Meckel's cave? An anatomical study. Surg Radiol Anat 2023:10.1007/s00276-023-03177-w. [PMID: 37318563 DOI: 10.1007/s00276-023-03177-w] [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: 12/28/2022] [Accepted: 05/27/2023] [Indexed: 06/16/2023]
Abstract
PURPOSE Dilatation of the trigeminal cavum, or Meckel's cave (MC), is usually considered a radiological sign of idiopathic intracranial hypertension. However, the normal size of the trigeminal cavum is poorly characterized. In this study, we describe the anatomy of this meningeal structure. METHODS We dissected 18 MCs and measured the length and width of the arachnoid web and its extension along the trigeminal nerve. RESULTS Arachnoid cysts were clearly attached to the ophthalmic (V1) and maxillary (V2) branches until they entered the cavernous sinus and foramen rotundum, respectively, without extension to the skull base. Arachnoid cysts were close to the mandibular branch toward the foramen ovale, with a median anteromedial extension of 2.5 [2.0-3.0] mm, lateral extension of 4.5 [3.0-6.0] mm, and posterior extension of 4.0 [3.2-6.0] mm. The trigeminal cavum arachnoid had a total width of 20.0 [17.5-25.0] mm and length of 24.5 [22.5-29.0] mm. CONCLUSION Our anatomical study revealed variable arachnoid extension, which may explain the variability in size of the trigeminal cavum in images and calls into question the value of this structure as a sign of idiopathic intracranial hypertension. The arachnoid web extends beyond the limits described previously, reaching almost double the radiological size of the cavum, particularly at the level of V3 afference of the trigeminal nerve. It is possible that strong adhesion of the arachnoid to the nerve elements prevents the formation of a true subarachnoid space that can be visualized by magnetic resonance imaging.
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Affiliation(s)
- Laetitia Le Petit
- Department of Neurosurgery A, University Hospital of Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux, France.
- Laboratory of Anatomy, University of Bordeaux, 33000, Bordeaux, France.
| | - Paul Roblot
- Department of Neurosurgery A, University Hospital of Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux, France
- Laboratory of Anatomy, University of Bordeaux, 33000, Bordeaux, France
| | - Arthur Durouchoux
- Department of Neurosurgery B, University Hospital of Bordeaux, Bordeaux, France
| | - Gaëlle Kerdiles
- Department of Neurosurgery A, University Hospital of Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux, France
- Laboratory of Anatomy, University of Bordeaux, 33000, Bordeaux, France
| | - Dominique Liguoro
- Department of Neurosurgery A, University Hospital of Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux, France
- Laboratory of Anatomy, University of Bordeaux, 33000, Bordeaux, France
| | - Vincent Jecko
- Department of Neurosurgery A, University Hospital of Bordeaux, Place Amélie Raba-Léon, 33076, Bordeaux, France
- Laboratory of Anatomy, University of Bordeaux, 33000, Bordeaux, France
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10
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Shibao S, Yoshida K. Simplified anterior transpetrosal approach without superior petrosal sinus and tentorial incision for lesions centered in Meckel's cave. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05584-9. [PMID: 37099067 DOI: 10.1007/s00701-023-05584-9] [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: 11/04/2022] [Accepted: 03/08/2023] [Indexed: 04/27/2023]
Abstract
OBJECTIVE The anterior transpetrosal approach (ATPA) is an effective method to reach lesions in the petroclival region. This approach involves many steps, including superior petrosal sinus (SPS) ligation and tentorial cutting. It is sometimes unnecessary to perform all procedures in the ATPA for certain lesions, especially those centered in the Meckel's cave. Here, we present a simplified anterior transpetrosal approach (SATPA) without superior petrosal sinus and tentorial incision for lesions centered in the Meckel's cave as a modified ATPA. METHODS This study included 13 patients treated with SATPA. The initial steps of SATPA are similar to ATPA, excluding a middle cranial fossa dural incision, SPS dissection, or tentorial incision. Histological examination was performed to understand the membrane structure of the trigeminal nerve, which runs through the Meckel's cave. RESULTS Pathology revealed trigeminal schwannoma (n=11), extraventricular central neurocytoma (n=1), and a metastatic tumor (n=1). The average tumor size was 2.4 cm. The total removal rate was 76.9% (10/13). Permanent complications included trigeminal neuropathy in four cases and cerebrospinal fluid leakage in one case. Histological examination revealed the trigeminal nerve traverses the subarachnoid space from the posterior fossa subdural space to the Meckel's cave and is covered with the epineurium in the inner reticular layer. CONCLUSIONS We used SATPA for lesions located in the Meckel's cave identified using histological examination. This approach may be considered for small- to medium-sized lesions centered in the Meckel space. CLINICAL TRIAL REGISTRATION NUMBER None.
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Affiliation(s)
- Shunsuke Shibao
- Department of Neurosurgery, Ashikaga Red Cross Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, 326-0843, Japan.
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan
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11
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Han X, Yang H, Wang Z, Li L, Li C, Han S, Wu A. Endoscopic transorbital approach for skull base lesions: a report of 16 clinical cases. Neurosurg Rev 2023; 46:74. [PMID: 36947242 DOI: 10.1007/s10143-023-01980-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/05/2023] [Accepted: 03/12/2023] [Indexed: 03/23/2023]
Abstract
Due to the deep location, complex anatomy, and adjacent vital neurovascular structures, skull base surgery is challenging and requires specific approaches. The emerging endoscopic transorbital approach (eTOA) technique provides a new approach to the orbital content, spheno-orbital region, lateral cavernous sinus, and Meckel's cave. In this study, the clinical utility and effectiveness of the eTOA are reported. Sixteen cases who underwent the eTOA were included in the current study. The patients were divided into 3 groups according to tumor location: Group A (intraorbital, 6 cases), group B (spheno-orbital, 7 cases), and group C (cavernous sinus, and Meckel's cave, 3 cases). The clinical data and surgical results were analyzed. Eight meningiomas, 2 hemangiomas, 1 low-grade glioma, 1 instance of inflammatory hyperplasia tissue, 1 Langerhans cell histiocytosis, 1 epidermoid cyst, 1 trigeminal schwannoma, and 1 bone fibrosis hyperplasia were observed. The mean tumor diameter was 2.4 cm. A single case in Group A and Group C underwent biopsy (12.5%), and 1 case of fibrous dysplasia in Group B underwent sufficient orbit decompression (6.25%). The remaining 13 cases underwent gross total tumor resection (81.25%). No cerebral-spinal fluid leak or infection occurred. And no cosmetic problems or significant complications were observed during the follow-up. As a minimally invasive technique, the eTOA has unique advantages for carefully selected skull base lesions because of its direct route, short working distance, and distinct attack angle.
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Affiliation(s)
- Xiaodi Han
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, 110001, China
| | - Hongyu Yang
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, 110001, China
- Department of Neurosurgery, Central Hospital of Chaoyang City, Chaoyang, 122000, China
| | - Zixun Wang
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, 110001, China
| | - Longjie Li
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, 110001, China
| | - Chenyu Li
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, 110001, China
| | - Sheng Han
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, 110001, China.
| | - Anhua Wu
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, 110001, China.
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12
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Zhong J. The Key to a Successful PBC in Treatment of Trigeminal Neuralgia. Acta Neurochir Suppl 2023; 135:161-165. [PMID: 38153465 DOI: 10.1007/978-3-031-36084-8_26] [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] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
As a minimally invasive treatment of trigeminal neuralgia, percutaneous balloon compression (PBC) has become increasingly popular worldwide. Because it is simple and straightforward, it does not need a complicated apparatus only a fluoroscope plus an operator's experience. Therefore, the surgical technique seems to be essential and worth further addressing. The paper stresses that the target of PBC should be the semilunar ganglion (the soma of neurons) rather than the rootlets (axons) because the latter is renewable. To obtain a sufficient pressure against the ganglion, Meckel's cave should be covered utterly by an inflating balloon, which fluoroscopically appears in a pear shape. To attain a proper balloon position, it is suggested to make a tunnel with a blunt stylet in a proper penetrative angle before inserting a soft catheter. Too large a pear is unnecessary, hence injecting should be stopped when growth becomes apparently slow. To avoid an unacceptable postoperative paresthesia, a prolonged compression is not encouraged.
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Affiliation(s)
- Jun Zhong
- Department of Neurosurgery, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.
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13
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Curcio A, Angileri FF, Zaccaria R, Germanò AF. Avoiding the Blinded Funnel: A Combined Single Piece Fronto-Temporo-Orbito-Zygomatic Craniotomy Endoscopic-Assisted Approach with Multimodal Assistance for an Epidermoid Tumor of Meckel's Cave-Case Report. Acta Neurochir Suppl 2023; 135:109-114. [PMID: 38153457 DOI: 10.1007/978-3-031-36084-8_18] [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] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
A Meckel's cave tumor poses a great challenge because of the peculiar neurovascular structure of the area and the deep location. Multiple surgical approaches have been designed for this area. In this report, we describe a case treated with a combined one step single piece fronto-temporo-orbito-zygomatic craniotomy (FTOZ) endoscopic-assisted approach for the treatment of an epidermoid tumor of Meckel's cave. A 51-year-old woman presented with a clinical history of left trigeminal neuralgia and paresthesia. CT imaging revealed a left basal temporal tumor. MR showed a tumor located in Meckel's cave near the cavernous sinus, with a good enhancement after gadolinium administration. The tumor was resected through a lateral basal subtemporal extradural approach followed by an intradural approach using intraoperative neuronavigation, endoscopic assistance, neurophysiological monitoring, and an intraoperative ultrasound probe. The lesion was completely removed. No new onset neurological damage has occurred. The symptoms improved following surgery. The aesthetic appearance of the patient was respected. The combined approach with a single piece fronto-temporo-orbito-zygomatic craniotomy has enabled us to work on a wider operating field to completely remove the lesion avoiding blind spots.
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Affiliation(s)
- A Curcio
- Department of Biomedical and Dental Science and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
| | - F F Angileri
- Department of Biomedical and Dental Science and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
| | - R Zaccaria
- Department of Biomedical and Dental Science and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy
| | - Antonino Francesco Germanò
- Department of Biomedical and Dental Science and Morphofunctional Imaging, Unit of Neurosurgery, University of Messina, Messina, Italy.
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14
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Matsushima K, Kohno M. Trigeminal Schwannoma Surgery: Challenges in Preserving Facial Sensation. Adv Tech Stand Neurosurg 2023; 46:95-107. [PMID: 37318571 DOI: 10.1007/978-3-031-28202-7_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Treatments of schwannoma have dramatically improved in the previous few decades, but preservation of the functions of the originating nerve, such as facial sensation in trigeminal schwannomas, still remains challenging. As the preservation of facial sensation in trigeminal schwannomas has not been analyzed in detail, we here review our surgical experience of more than 50 trigeminal schwannoma patients, particularly focusing on their facial sensation. Since the facial sensation in each trigeminal division showed a different perioperative course even in a single patient, we investigated patient-based outcomes (average of the three divisions in each patient) and division-based outcomes separately. In the evaluation of patient-based outcomes, facial sensation remained postoperatively in 96% of all the patients, and improved in 26% and worsened in 42% of patients with preoperative hypesthesia. Posterior fossa tumors tended to most rarely disrupt facial sensation preoperatively, but were the most difficult to preserve facial sensation postoperatively. Facial pain was relieved in all six patients with preoperative neuralgia. In the division-based evaluation, facial sensation remained postoperatively in 83% of all the trigeminal divisions, and improved in 41% and worsened in 24% of the divisions with preoperative hypesthesia. The V3 region was most favorable before and after surgery, with the most frequent improvement and the least frequent functional loss. To clarify current treatment outcomes of the facial sensation and to achieve more effective preservation, standardized assessment methods of perioperative facial sensation may be required. We also introduce detailed MRI investigation methods for schwannoma, including contrast-enhanced heavily T2-weighted (CISS) imaging, arterial spin labeling (ASL), and susceptibility-weighted imaging (SWI), preoperative embolization for rare vascular-rich tumors, and modified techniques of the transpetrosal approach.
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Affiliation(s)
- Ken Matsushima
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Michihiro Kohno
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan.
- Department of Neurosurgery, Tokyo Metropolitan Police Hospital, Tokyo, Japan.
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15
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Jeyaraj P. Efficiency and Efficacy of Real-Time Fluoroscopic Image-Guided Percutaneous Gasserian Glycerol Rhizotomy (PGGR), for Intractable Cases of Trigeminal Neuralgia. J Maxillofac Oral Surg 2022; 21:1053-1064. [PMID: 36896085 PMCID: PMC9989047 DOI: 10.1007/s12663-021-01682-2] [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: 06/21/2021] [Accepted: 12/15/2021] [Indexed: 11/27/2022] Open
Abstract
Aim & Objectives To evaluate the ease, efficiency, effectiveness, and associated complications of the technique of percutaneous Gasserian glycerol rhizotomy (PGGR) under real-time fluoroscopic image guidance, for management of severe and refractory cases of primary trigeminal neuralgia, in medical compromised patients. To also assess the long-term efficacy and the necessity, if any, for repeat procedures to salvage recurrences. Study Design & Setting In a prospective study conducted at a single institution over a period of three years, 25 cases of Idiopathic Trigeminal Neuralgia refractory to conservative modalities of treatment including medication were managed with PGGR under real-time fluoroscopic image guidance. All the 25 patients included in this study were known surgical risks for relatively invasive treatment procedures, owing to factors such as advanced age and/or presence of co-morbidities. Material & Methods In order to minimize the risks related to the conventional techniques of Trigeminal root rhizotomy based on cutaneous landmarks alone, and to eliminate the need for frequent repositioning of the needle/cannula, we adopted a technique of real-time fluoroscopic image-guided negotiation of a 22 gauge (0.7 mm dia), 10-cm-long spinal nerve block needle through the foramen ovale, to reach the trigeminal cistern within the Meckel's cave. The efficiency of the technique was assessed in terms of time taken, effort, and ease in performing it. Associated intra- and post-procedural complications were recorded. The immediate and long-term effectiveness of the procedure was evaluated by analysing the degree and duration of pain control achieved, time to recurrence, and the necessity for repeat procedures. Results & Conclusion There were nil intra- or post-procedural complications encountered, and no failures associated with this procedure. Real-time fluoroscopic imaging enabled easy, quick, and successful negotiation of the nerve-block needle through the Foramen Ovale, so as to reach the Trigeminal cistern within the Meckel's cave, within 11 min on an average. An immediate and long lasting post-procedural pain relief was achieved in all the patients. During the follow-up period of 36 months, recurrence of pain was observed in six cases, the mean timing of the recurrence being 26 months or more. Five of these cases were manageable with medication alone, and only one required a repeat procedure. These results indicate that PGGR under real-time fluoroscopic image guidance is a safe, simple, time-efficient, convenient, efficacious, reliable, and minimally invasive means of treating refractory and intractable cases of trigeminal neuralgia.
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Affiliation(s)
- Priya Jeyaraj
- Classified Specialist (Oral & Maxillofacial Surgery), Commanding Officer 33 CDU and 33 Corps Dental Adviser, Indian Army, West Bengal, India
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16
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Murata T, Matsuda M, Shinozaki T, Ishiyama K. Glioblastoma, IDH-wildtype with leptomeningeal metastasis to Meckel's cave: A case report. Acta Radiol Open 2022; 11:20584601221131480. [PMID: 36225898 PMCID: PMC9549091 DOI: 10.1177/20584601221131480] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Meckel’s cave or the trigeminal cistern is a subarachnoid space near the apex of
the petrous portion of the temporal bone and contains cerebrospinal fluid and
the Gasserian ganglion, which divides into the ophthalmic (V1), maxillary (V2),
and mandibular (V3) nerves. Infectious, inflammatory, congenital, and neoplastic
lesions can occur in Meckel’s cave. Leptomeningeal metastasis of glioblastoma
(GBM), IDH-wildtype to Meckel’s cave is rare. We encountered a case of
leptomeningeal metastasis of GBM to Meckel’s cave in an elderly female patient
who presented with pain around her right eye. Magnetic resonance imaging
revealed enhancing lesions in the right temporal lobe and cervical spinal cord.
The pathological diagnosis of GBM was confirmed after biopsy of the cervical
spinal cord lesion, which showed hyperaccumulation of fluorodeoxyglucose (FDG)
on FDG-positron emission tomography. This case indicates that metastatic lesions
can also occur in Meckel’s cave.
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Affiliation(s)
| | - Masazumi Matsuda
- Masazumi Matsuda, Department of Radiology,
Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita 010-8543,
Japan.
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17
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Wen Y, Li YM, Zhu B, Liu X, Zhao M. Isolated intracranial xanthogranuloma involving the Meckel's cave in an adult: a case report. Acta Neurol Belg 2022; 122:555-557. [PMID: 34043212 DOI: 10.1007/s13760-021-01715-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/19/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Yang Wen
- Departments of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yu-Mei Li
- Departments of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Biao Zhu
- Departments of Neurosurgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xin Liu
- Departments of Neurosurgery, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Ming Zhao
- Departments of Pathology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, Hangzhou, China.
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18
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Sun C, Zheng W, Zhu Q, Du Q, Yu W. The Transformation of the Balloon Shape in Percutaneous Balloon Compression for Trigeminal Neuralgia. J Pain Res 2021; 14:3805-3814. [PMID: 34934354 PMCID: PMC8684418 DOI: 10.2147/jpr.s343783] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/06/2021] [Indexed: 11/23/2022] Open
Abstract
Background The pear shape of an inflated balloon is thought to be a gold standard of successful percutaneous balloon compression (PBC). However, neither how nor why it changes in that way (the anatomic basis) has not yet been fully described. Aim In this article, we try to describe how the balloon in Meckel’s cave (MC) should appear and why; and identify which shapes are good pear shapes, which shapes are not good pear shapes, and which shapes are intermediate. Methods Radiographs from over 150 percutaneous balloon compression (PBC) cases were thoroughly evaluated. We proposed a model of changing balloon shape in MC and 70 cases were followed up over two years, in which therapeutic effect was measured. Results We found that the balloon changed stereotypically in MC. The model that we proposed is consistent with the description of MC’s structures and its’ surroundings in the literature. The distinct pear (pear in MC) brought about a far better surgical result than other shapes (p < 0.01). Conclusion Our study showed how and why the balloon shape changed during PBC surgery. The model provides clear guidance for PBC surgery.
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Affiliation(s)
- Chenglong Sun
- Department of Neurosurgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Wenhao Zheng
- The Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, People's Republic of China
| | - Qiang Zhu
- Department of Neurosurgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Quan Du
- Department of Neurosurgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
| | - Wenhua Yu
- Department of Neurosurgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China.,Department of Neurosurgery, Hangzhou Ninth People's Hospital, Hangzhou, People's Republic of China
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Kim SK, Fujii T, Komaki R, Kobayashi H, Okuda T, Fujii Y, Hayakumo T, Yuasa K, Takami M, Ohtani A, Saijo Y, Koma YI, Kim SR. Distant metastasis of hepatocellular carcinoma to Meckel’s cave and cranial nerves: A case report and review of literature. World J Hepatol 2021; 13:709-716. [PMID: 34239705 PMCID: PMC8239490 DOI: 10.4254/wjh.v13.i6.709] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/29/2021] [Accepted: 06/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Metastasis occurs as a late event in the natural history of hepatocellular carcinoma (HCC), and most patients die of liver failure attributed to the tumor supplanting the liver. Conversely, the brain is a less common metastatic site.
CASE SUMMARY We describe a rare case of hepatitis C virus-related multiple HCC metastasizing to the cavernous sinus, Meckel’s cave, and the petrous bone involving multiple cranial nerves in an 82-year-old woman. At admission imaging studies including Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (MRI) revealed multiple HCC nodules in both right and left lobes. Ultrasound guided biopsy of the left lobe revealed moderately differentiated HCC. Molecular targeted therapy with Lenvatinib (8 mg/d for 94 d, per os) and Ramucirumab (340 mg/d and 320 mg/d, two times by intravenous injection) were administered for 4 mo, resulting in progression of the disease. Three months after the start of molecular target therapy, the patient presented with symptoms of hyperalgesia of the right face and limited abduction of the right eye, indicating disturbances in the right trigeminal and abducens nerves. Brain MRI disclosed a mass involving the cavernous sinus, Meckel’s cave and the petrous bone. Contrast-enhanced MRI with gadolinium-chelated contrast medium revealed a well-defined mass with abnormal enhancement around the right cavernous sinus and the right Meckel’s cave.
CONCLUSION The diagnosis of metastatic HCC to the cavernous sinus, Meckel’s cave, and the petrous bone was made based on neurological findings and imaging studies including MRI, but not on histological examinations. Further studies may provide insights into various methods for diagnosing HCC metastasizing to the craniospinal area.
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Affiliation(s)
- Soo Ki Kim
- Department of Gastroenterology, Kobe Asahi Hospital, Kobe 653-0801, Hyogo, Japan
| | - Takako Fujii
- Department of Gastroenterology, Kobe Asahi Hospital, Kobe 653-0801, Hyogo, Japan
| | - Ryouhei Komaki
- Division of Neurology, Kobe University Graduate School of Medicine, Kobe 650-0017, Hyogo, Japan
| | - Hisato Kobayashi
- Department of Radiology, Kobe Asahi Hospital, Kobe 653-0801, Hyogo, Japan
| | - Toyokazu Okuda
- Department of Gastroenterology, Kobe Asahi Hospital, Kobe 653-0801, Hyogo, Japan
| | - Yumi Fujii
- Department of Gastroenterology, Kobe Asahi Hospital, Kobe 653-0801, Hyogo, Japan
| | - Takanobu Hayakumo
- Department of Gastroenterology, Kobe Asahi Hospital, Kobe 653-0801, Hyogo, Japan
| | - Kanako Yuasa
- Department of Gastroenterology, Kobe Asahi Hospital, Kobe 653-0801, Hyogo, Japan
| | - Masahiro Takami
- Department of Gastroenterology, Kobe Asahi Hospital, Kobe 653-0801, Hyogo, Japan
| | - Aya Ohtani
- Department of Pharmacy, Kobe Asahi Hospital, Kobe 653-0801, Hyogo, Japan
| | - Yuka Saijo
- Department of Pharmacy, Kobe Asahi Hospital, Kobe 653-0801, Hyogo, Japan
| | - Yu-Ichiro Koma
- Department of Pathology, Kobe University Graduate School of Medicine, Kobe 650-0017, Hyogo, Japan
| | - Soo Ryang Kim
- Department of Gastroenterology, Kobe Asahi Hospital, Kobe 653-0801, Hyogo, Japan
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Hanakita S, Oya S, Matsui T. Trigeminal neuralgia caused by an arachnoid cyst in Meckel's cave: A case report and literature review. Surg Neurol Int 2021; 12:45. [PMID: 33654548 PMCID: PMC7911133 DOI: 10.25259/sni_734_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/19/2021] [Indexed: 12/03/2022] Open
Abstract
Background: We present a rare case of trigeminal neuralgia (TN) caused by an arachnoid cyst (AC) in Meckel’s cave (MC). Case Description: A 35-year-old man presented with facial pain in the left maxillary and mandibular regions. Since the initial magnetic resonance (MR) imaging showed no apparent offending vessels or tumors, the patient was diagnosed with idiopathic TN, for which carbamazepine was initially effective. When his pain worsened, he was referred to our hospital. A slightly asymmetric shape of MC and distorted course of the trigeminal nerve was confirmed on the initial and repeat MR images. His pain was characterized as electric-shock-like pain, which was triggered by touching the face. Under the tentative diagnosis of an AC confined to MC compressing the trigeminal nerve, the exploration of MC through suboccipital craniotomy was performed. Intraoperatively, the AC was identified in the rostral portion of MC. The indentation of the trigeminal nerve was also observed at the orifice of MC, indicating severe compression by the AC. The wall of the AC was fenestrated. The patient’s pain was relieved immediately after surgery. Postoperative MR images showed that the course of the trigeminal nerve was straightened. Although our literature review found five similar cases, the size of the AC was the smallest in our case. Conclusion: Although it is rare, the AC confined to MC can cause TN. The findings of this study emphasize the importance of evaluating subtle radiological findings of compression on the trigeminal nerve in cases of TN seemingly without neurovascular compression.
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Affiliation(s)
- Shunya Hanakita
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Toru Matsui
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
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21
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Suero Molina E, Revuelta Barbero JM, Ewelt C, Stummer W, Carrau RL, Prevedello DM. Access to Meckel's cave for biopsies of indeterminate lesions: a systematic review. Neurosurg Rev 2021; 44:249-259. [PMID: 32040778 PMCID: PMC7850998 DOI: 10.1007/s10143-020-01247-w] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/20/2020] [Indexed: 01/12/2023]
Abstract
Accessing Meckel's cave (MC) is surgically challenging. Open approaches are complex and often correlated with high morbidity. Endoscopic approaches emerged in the last decade as feasible alternatives to open approaches, especially for sampling indeterminate lesions. This article first analyses available routes to approach Meckel's cave and presents furthermore an illustrative case. We conducted a systematic review and reported according to the guidelines for preferred reporting items for systematic reviews and meta-analyses (PRISMA). Various surgical approaches identified through the search are evaluated and discussed in detail. Additionally, we report on a case of woman with a lesion in MC, which was accessed through an endoscopic transpterygoid approach subsequently diagnosed as a diffuse large B cell lymphoma. Our search delivered 75 articles that included case reports (n = 21), cadaveric studies (n = 32), clinical articles (n = 16), review of the literatures (n = 3), as well as technical notes (n = 2) and a radiological manuscript (n = 1). Open routes included lateral approaches with many variations, mainly intra- and extradural pterional approaches and anterior petrosal, as well as a retrosigmoid intradural suprameatal and a lateral transorbital approach. Endoscopically, MC was reached via approaches that included transpterygoid, transorbital or infraorbital fissure routes. Percutaneous approaches, e.g. through the foramen ovale, were also described. Multiple surgical approaches to MC are currently available. Their different characteristics as well as individual patient factors, such as clinical history and the localization of the disease, have to be considered when choosing a surgical corridor. Studies included in this review highlight the endonasal endoscopic transpterygoidal technique as an excellent corridor for biopsies in the ventral MC.
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Affiliation(s)
- E Suero Molina
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149, Munster, Germany.
| | - J M Revuelta Barbero
- Department of Otolaryngology-Head and Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
- Department of Neurological Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - C Ewelt
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149, Munster, Germany
| | - W Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149, Munster, Germany
| | - R L Carrau
- Department of Otolaryngology-Head and Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
- Department of Neurological Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - D M Prevedello
- Department of Otolaryngology-Head and Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
- Department of Neurological Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
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22
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Almomen A, Alyousif A, Ali Z, Al Yaeesh I, AlOmirin A, Al Yahya A, AlSuqair H, Almolani F. Image-guided endonasal endoscopic excision of Meckel's cave trigeminal schwannoma from cavernous and petrous carotid artery. J Surg Case Rep 2020; 2020:rjaa374. [PMID: 33024535 PMCID: PMC7526469 DOI: 10.1093/jscr/rjaa374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/17/2020] [Indexed: 11/21/2022] Open
Abstract
Trigeminal schwannoma is the second most common schwannoma after vestibular schwannoma. Symptoms vary depending on the anatomical structures affected by the tumor, including facial pain, paresthesia, dizziness and ataxia. The primary goals are controlling the symptoms and the maintenance of cranial nerves’ integrity perioperatively. We report a 39-year-old lady who was complaining of mild right-sided headache, vision and hearing loss, right facial weakness and dysphagia. CT and MRI showed a large dumbbell-shaped tumor originating from the trigeminal fossa abutting the petrous and cavernous carotid artery and extending to the infratemporal fossa. An image-guided endonasal endoscopic removal was successfully done. Image-guided endonasal endoscopic removal of a trigeminal schwannoma abutting the petrous and cavernous carotid artery and extending to the infratemporal fossa is a safe, effective approach, as it offers excellent visualization, accurate localization and safe dissection of the tumor from the critical anatomical neurovascular structures surrounding it.
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Affiliation(s)
- Ali Almomen
- Rhinology and Skull Base Surgery, KFSH, MOH, Dammam, Saudi Arabia
| | | | - Zainab Ali
- Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | | | | | | | | | - Fadhel Almolani
- Interventional and Neuroradiology, KFSH, MOH, Dammam, Saudi Arabia
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23
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Di Somma A, Langdon C, de Notaris M, Reyes L, Ortiz-Perez S, Alobid I, Enseñat J. Combined and simultaneous endoscopic endonasal and transorbital surgery for a Meckel's cave schwannoma: technical nuances of a mini-invasive, multiportal approach. J Neurosurg 2020; 134:1836-1845. [PMID: 32650309 DOI: 10.3171/2020.4.jns20707] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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: 03/15/2020] [Accepted: 04/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Over the years, Meckel's cave pathologies have been judged off-limits because of high rates of morbidity. Even though several studies have defined various surgical routes with tolerable morbidity and mortality rates, controversies related to the optimal avenue to treat different categories of Meckel's cave and cavernous sinus neoplasms persist.With unceasing energy to cultivate minimally invasive neurosurgical approaches, the endoscopic endonasal route has been tested, and the approach effectively performed, to provide a valid surgical window to these areas. In this dynamic and challenging scenario, another ventral endoscopic minimally invasive route-that is, the superior eyelid endoscopic transorbital approach-has been very recently proposed, and used in selected cases, to access the cavernous sinus and Meckel's cave regions. METHODS The authors report the technical nuances of a combined and simultaneous endoscopic endonasal and transorbital surgical treatment of a patient with a Meckel's cave schwannoma. The operation involved collaboration among neurosurgery, otorhinolaryngology, and ophthalmology (oculoplastic surgery). The patient recovered well, had no neurological deficits, and was discharged to home 3 days after surgery. RESULTS The multiportal combined route was proposed for the following reasons. The endonasal approach, considered to be more familiar to our skull base team, could allow control of possible damage of the internal carotid artery. From the endonasal perspective, the most inferior and medial portion of the tumor could be properly managed. Finally, the transorbital route, by means of opening the lateral wall of the cavernous sinus via the meningoorbital band, could allow control of the superolateral part of the tumor and, most importantly, could permit removal of the portion entering the posterior cranial fossa via the trigeminal pore. Simultaneous surgery with two surgical teams working together was planned in order to reduce operative time, hospital stay, and patient stress and discomfort, and to ensure "one-shot" complete tumor removal, with minimal or no complications. CONCLUSIONS This study represents the translation into the real surgical setting of recent anatomical contributions related to the novel endoscopic transorbital approach and its simultaneous integration with the endoscopic endonasal pathway. Accordingly, it may pave the way for future applications related to minimally invasive, multiportal endoscopic surgery for skull base tumors.
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Affiliation(s)
| | | | | | | | - Santiago Ortiz-Perez
- 4Department of Ophthalmology, Hospital Clínic de Barcelona; and.,5Department of Ophthalmology, Hospital Virgen de las Nieves, Granada, Spain
| | - Isam Alobid
- 3Department of Neuroscience, "G. Rummo" Hospital, Benevento, Italy
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Oishi M, Fujisawa H, Tsuchiya K, Nakajima Y. The Importance of STAT6 in a Schwannoma-like Grade III Solitary Fibrous Tumor/Hemangiopericytoma Located in the Cerebellopontine Angle and Meckel's Cave. World Neurosurg 2020; 141:500-506.e1. [PMID: 32526357 DOI: 10.1016/j.wneu.2020.05.262] [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: 04/05/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hemangiopericytoma (HPC) is a rare mesenchymal tumor of the brain that occurs in the central nervous system as a solitary fibrous tumor. Surgical treatment of HPC is known to be beneficial, but results on the role of complete resection and adjuvant radiation are conflicting. However, it is often difficult to detect a central nervous system solitary fibrous tumor/HPC before surgery. We describe a presumed left trigeminal schwannoma that was histopathologically shown to be an HPC. CASE DESCRIPTION A 65-year-old man presented with paresthesia of the second and third branches of the left trigeminal nerve. Magnetic resonance imaging showed a tumoral lesion in the left cerebellopontine angle and Meckel's cave. We suspected a schwannoma and performed surgery, which resulted in only a partial resection because of tumor bleeding and unexpected intraoperative histologic findings. We could not achieve a definitive diagnosis. However, we observed local recurrence and disseminated lesions 5 and 6.5 years later, respectively. We performed a second surgery and were able to definitively diagnose the lesion as a grade III HPC based on the positive expression of STAT6 during immunostaining. CONCLUSIONS As solitary fibrous tumor/HPC requires gross total resection for effective resolution, it is imperative to consider it in the differential diagnoses of similar tumors. If an unusual pathologic image is found, we recommend rapid immunostaining for STAT6 to reach a definitive conclusion regarding the tumor type. This case highlights the importance of considering HPC when screening or diagnosing central nervous system lesions, especially in this rare location.
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Affiliation(s)
- Masahiro Oishi
- Department of Neurosurgery, National Hospital Organization Kanazawa Medical Center, Ishikawa, Japan. ]
| | - Hironori Fujisawa
- Department of Neurosurgery, National Hospital Organization Kanazawa Medical Center, Ishikawa, Japan
| | - Katsuhiro Tsuchiya
- Department of Neurosurgery, National Hospital Organization Kanazawa Medical Center, Ishikawa, Japan
| | - Yoshio Nakajima
- Department of Neurosurgery, National Hospital Organization Kanazawa Medical Center, Ishikawa, Japan
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Wu X, Xie SH, Tang B, Yang L, Xiao LM, Ding H, Bao YY, Tong ZG, Hong T. Single-stage endoscopic endonasal approach for the complete removal of trigeminal schwannomas occupying both the middle and posterior fossae. Neurosurg Rev 2020; 44:607-616. [PMID: 32076898 DOI: 10.1007/s10143-020-01266-7] [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: 11/11/2019] [Revised: 01/03/2020] [Accepted: 02/10/2020] [Indexed: 10/25/2022]
Abstract
To introduce a purely endoscopic endonasal trans-Meckel's cave approach or a transclival approach for trigeminal schwannomas (TSs) involving both the middle and posterior fossae. This retrospective study reviewed the medical records and intraoperative videos of 8 patients with TSs occupying both the middle and posterior fossae who underwent an endoscopic endonasal approach (EEA) between January 2017 and October 2019. All 8 patients received total resection under a single-stage EEA. Six patients underwent endoscopic endonasal resection via a purely trans-Meckel's cave approach, and 2 patients underwent endoscopic endonasal resection via a trans-Meckel's cave approach combined with a transclival approach. There was no surgical-related hemorrhage or mortality and no cerebrospinal fluid leakage. All headache symptoms completely improved postoperatively (n = 3 patients). All cranial nerve (CN) symptoms (CN IX and CN VI) improved postoperatively. The most common preoperative symptom was facial numbness (n = 5 patients); 2 of these 5 patients showed a partial improvement, 1 patient experienced worsening, and 2 patients remained unchanged at the last follow-up. Four patients developed postoperative complications, including CN VI palsy (n = 2), dry eye (n = 2), mastication weakness (n = 1), and facial numbness (n = 2). All complications except for dry eye were relieved at the last follow-up, but the patients with dry eye did not develop corneal keratopathy. The endoscopic endonasal trans-Meckel's cave and transclival approaches provide adequate exposure and improve the rate of total resection for TSs occupying both the middle and posterior fossae with minimal invasion. It may be possible to use these approaches as a safe alternative to conventional surgical approaches.
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Affiliation(s)
- Xiao Wu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Shen Hao Xie
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Bin Tang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Le Yang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Li Min Xiao
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Han Ding
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - You Yuan Bao
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Zhi Gao Tong
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China
| | - Tao Hong
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, China.
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26
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Karschnia P, Sengupta S, Dietrich J. MRI findings in trigeminal neuropathy: bilateral Meckel's cave lesions. Acta Neurol Belg 2020; 120:171-173. [PMID: 30712245 DOI: 10.1007/s13760-019-01091-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/29/2019] [Indexed: 10/27/2022]
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27
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Wu X, Wang X, Song G, Li M, Chen G, Guo H, Bao Y, Liang J. Simultaneous hemorrhage of multiple cerebral cavernous malformations of the insular lobe and Meckel's cave: a case report and literature review. Br J Neurosurg 2019:1-5. [PMID: 31790277 DOI: 10.1080/02688697.2019.1687847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We describe a case of sporadic cavernous malformation (CM) in a patient suffering from multiple hemorrhagic intracranial lesions, including one originating from the trigeminal nerve (TN). The patient presented with left side facial pain and disturbed right limb movement. The patient was pre-operatively diagnosed with multiple cerebral CMs. This diagnosis was confirmed by postoperative pathology.
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Affiliation(s)
- Xiaolong Wu
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Xu Wang
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Gang Song
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Mingchu Li
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Ge Chen
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Hongchuan Guo
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Yuhai Bao
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Jiantao Liang
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
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28
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Cleary DR, Handwerker J, Ansari H, Ben-Haim S. Three Cases of Trigeminal Neuralgia with Radiographic Absence of Meckel's Cave. Stereotact Funct Neurosurg 2019; 97:249-254. [PMID: 31661697 DOI: 10.1159/000502564] [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: 12/28/2018] [Accepted: 08/08/2019] [Indexed: 11/19/2022]
Abstract
Trigeminal neuralgia (TN) is a debilitating but treatable disease. Classic TN has referable vascular compression of the trigeminal nerve, but rarely secondary sources of anatomic compression will present, including vascular malformations, aneurysms, or tumors. Understanding the etiology of the patients' symptoms leads to targeted treatment. Three patients presented with symptoms consistent with TN: shooting, paroxysmal pains in the distribution of the trigeminal nerve. However, imaging revealed no vascular conflict at the root entry zone of the trigeminal nerve. Instead, on the affected side Meckel's cave was absent. No other compressive mass lesion was identified. In all three cases, patients were offered both Gamma Knife Radiosurgery and surgical decompression of Meckel's cave. All 3 patients elected to proceed with stereotactic radiation and reported improvement in pain. Many cases of classic TN can be explained by neurovascular conflict at the trigeminal root entry zone, but secondary sources of compression or restriction along the nerve can result in similar symptomology. In this case series, an absent or hypoplastic ipsilateral Meckel's cave may have produced symptoms consistent with TN. Imaging with fine cuts through Meckel's cave is an important diagnostic tool.
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Affiliation(s)
- Daniel R Cleary
- Department of Neurological Surgery, University of California San Diego, San Diego, California, USA
| | - Jason Handwerker
- Department of Radiology, University of California San Diego, San Diego, California, USA
| | - Hossein Ansari
- Department of Neurosciences, University of California San Diego, San Diego, California, USA
| | - Sharona Ben-Haim
- Department of Neurological Surgery, University of California San Diego, San Diego, California, USA,
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29
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Truong HQ, Sun X, Celtikci E, Borghei-Razavi H, Wang EW, Snyderman CH, Gardner PA, Fernandez-Miranda JC. Endoscopic anterior transmaxillary "transalisphenoid" approach to Meckel's cave and the middle cranial fossa: an anatomical study and clinical application. J Neurosurg 2019; 130:227-237. [PMID: 29393751 DOI: 10.3171/2017.8.jns171308] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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: 05/28/2017] [Accepted: 08/08/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Multiple approaches have been designed to reach the medial middle fossa (for lesions in Meckel's cave, in particular), but an anterior approach through the greater wing of the sphenoid (transalisphenoid) has not been explored. In this study, the authors sought to assess the feasibility of and define the anatomical landmarks for an endoscopic anterior transmaxillary transalisphenoid (EATT) approach to Meckel's cave and the middle cranial fossa. METHODS Endoscopic dissection was performed on 5 cadaver heads injected intravascularly with colored silicone bilaterally to develop the approach and define surgical landmarks. The authors then used this approach in 2 patients with tumors that involved Meckel's cave and provide their illustrative clinical case reports. RESULTS The EATT approach is divided into the following 4 stages: 1) entry into the maxillary sinus, 2) exposure of the greater wing of the sphenoid, 3) exposure of the medial middle fossa, and 4) exposure of Meckel's cave and lateral wall of the cavernous sinus. The approach provided excellent surgical access to the anterior and lateral portions of Meckel's cave and offered the possibility of expanding into the infratemporal fossa and lateral middle fossa and, in combination with an endonasal transpterygoid approach, accessing the anteromedial aspect of Meckel's cave. CONCLUSIONS The EATT approach to Meckel's cave and the middle cranial fossa is technically feasible and confers certain advantages in specific clinical situations. The approach might complement current surgical approaches for lesions of Meckel's cave and could be ideal for lesions that are lateral to the trigeminal ganglion in Meckel's cave or extend from the maxillary sinus, infratemporal fossa, or pterygopalatine fossa into the middle cranial fossa, Meckel's cave, and cavernous sinus, such as schwannomas, meningiomas, and sinonasal tumors and perineural spread of cutaneous malignancy.
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Affiliation(s)
| | - Xicai Sun
- Departments of1Neurological Surgery and.,2Department of Otolaryngology, Eye, Ear, Nose, and Throat Hospital, Shanghai Medical College of Fudan University, Shanghai, People's Republic of China
| | | | | | - Eric W Wang
- 3Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Carl H Snyderman
- 3Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
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30
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Zoli M, Ratti S, Guaraldi F, Milanese L, Pasquini E, Frank G, Billi AM, Manzoli L, Cocco L, Mazzatenta D. Endoscopic endonasal approach to primitive Meckel's cave tumors: a clinical series. Acta Neurochir (Wien) 2018; 160:2349-2361. [PMID: 30382359 DOI: 10.1007/s00701-018-3708-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 10/16/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Recently, an alternative endoscopic endonasal approach to Meckel's cave (MC) tumors has been proposed. To date, few studies have evaluated the results of this route. The aim of our study was to evaluate long-term surgical and clinical outcome associated with this technique in a cohort of patients with intrinsic MC tumors. METHODS All patients with MC tumors treated at out institution by endoscopic endonasal approach (EEA) between 2002 and 2016 were included. Patients underwent brain MRI, CT angiography, and neurological evaluation before surgery. Complications were considered based on the surgical records. All examinations were repeated after 3 and 12 months, then annually. The median follow-up was of 44.1 months (range 16-210). RESULTS The series included 8 patients (4 F): 5 neuromas, 1 meningioma, 1 chondrosarcoma, and 1 epidermoid cyst. The median age at treatment was 54.5 years (range 21-70). Three tumors presented with a posterior fossa extension. Radical removal of the MC portion of the tumor was achieved in 7 out of 8 cases. Two patients developed a permanent and transitory deficit of the sixth cranial nerve, respectively. No tumor recurrence was observed at follow-up. CONCLUSION In this preliminary series, the EEA appeared an effective and safe approach to MC tumors. The technique could be advantageous to treat tumors located in the antero-medial aspects of MC displacing the trigeminal structures posteriorly and laterally. A favorable index of an adequate working space for this approach is represented by the ICA medialization, while tumor extension to the posterior fossa represents the main limitation to radical removal of this route.
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31
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Jeon C, Hong CK, Woo KI, Hong SD, Nam DH, Lee JI, Choi JW, Seol HJ, Kong DS. Endoscopic transorbital surgery for Meckel's cave and middle cranial fossa tumors: surgical technique and early results. J Neurosurg 2018; 131:1-10. [PMID: 30544350 DOI: 10.3171/2018.6.jns181099] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [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: 04/23/2018] [Accepted: 06/27/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVETumors involving Meckel's cave remain extremely challenging because of the surrounding complex neurovascular structures and deep-seated location. The authors investigated a new minimal-access technique using the endoscopic transorbital approach (eTOA) through the superior eyelid crease to Meckel's cave and middle cranial fossa lesions and reviewed the most useful surgical procedures and pitfalls of this approach.METHODSBetween September 2016 and January 2018, the authors performed eTOA in 9 patients with tumors involving Meckel's cave and the middle cranial fossa. The lesions included trigeminal schwannoma in 4 patients, meningioma in 2 patients, metastatic brain tumor in 1 patient, chondrosarcoma in 1 patient, and dermoid cyst in 1 patient. In 7 of the 9 patients, eTOA alone was performed, while the other 2 patients underwent a combined eTOA and endoscopic endonasal approach or retrosigmoid craniotomy. Data including details of surgical techniques and clinical outcomes were recorded.RESULTSGross-total resection was performed in 7 of the 9 patients (77.8%). Four patients underwent extended eTOA (with lateral orbital rim osteotomy). Drilling of the trapezoid sphenoid floor, a middle fossa "peeling" technique, and full visualization of Meckel's cave were applied to approach the lesions. Tumors were exposed and removed extradurally in 3 patients and intradurally in 6 patients. There was no postoperative CSF leak.CONCLUSIONSThe eTOA affords a direct route to access Meckel's cave and middle cranial fossa lesions. With experience, this novel approach can be successfully applied to selected skull base lesions. To achieve successful removal of the tumor, emphasis should be placed on the importance of adequately removing the greater sphenoid wing and vertical crest. However, because of limited working space eTOA may not be an ideal approach for posterior fossa lesions.
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Affiliation(s)
| | - Chang-Ki Hong
- 2Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | | | - Sang Duk Hong
- 4Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine; and
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Sundararajan S, Loevner LA, Mohan S. Mandibular Myalgia and Miniscule Meckel's Caves. ORL J Otorhinolaryngol Relat Spec 2018; 80:103-107. [PMID: 29996129 DOI: 10.1159/000489462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 04/17/2018] [Indexed: 11/19/2022]
Abstract
Trigeminal neuropathy manifests as episodic sharp, shooting pain in the maxillofacial region. Contributory etiologies are myriad, ranging from central pathology affecting its origin in the brainstem to peripheral processes affecting their distal-most insertion sites. We present a case of bilateral hypoplastic Meckel's caves in an adult patient leading to the clinical symptomology of trigeminal neuralgia. To the best of our knowledge, this is the only report of its kind highlighting this anatomic variant.
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Malhotra A, Tu L, Kalra VB, Wu X, Mian A, Mangla R, Michaelides E, Sanelli P, Gandhi D. Neuroimaging of Meckel's cave in normal and disease conditions. Insights Imaging 2018; 9:499-510. [PMID: 29671218 PMCID: PMC6108963 DOI: 10.1007/s13244-018-0604-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [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: 11/27/2017] [Revised: 01/24/2018] [Accepted: 02/01/2018] [Indexed: 12/19/2022] Open
Abstract
Abstract Meckel’s cave is a dural recess in the posteromedial portion of the middle cranial fossa that acts as a conduit for the trigeminal nerve between the prepontine cistern and the cavernous sinus, and houses the Gasserian ganglion and proximal rootlets of the trigeminal nerve. It serves as a major pathway in perineural spread of pathologies such as head and neck neoplasms, automatically upstaging tumours, and is a key structure to assess in cases of trigeminal neuralgia. The purpose of this pictorial review is threefold: (1) to review the normal anatomy of Meckel’s cave; (2) to describe imaging findings that identify disease involving Meckel’s cave; (3) to present case examples of trigeminal and non-trigeminal processes affecting Meckel’s cave. Teaching points • Meckel’s cave contains the trigeminal nerve between prepontine cistern and cavernous sinus. • Assessment is essential for perineural spread of disease and trigeminal neuralgia. • Key imaging: neural enhancement, enlargement, perineural fat/CSF effacement, skull base foraminal changes.
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Affiliation(s)
- Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Box 208042, Tompkins East 2, 333 Cedar St, New Haven, CT, 06520-8042, USA.
| | - Long Tu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Box 208042, Tompkins East 2, 333 Cedar St, New Haven, CT, 06520-8042, USA
| | | | - Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Box 208042, Tompkins East 2, 333 Cedar St, New Haven, CT, 06520-8042, USA
| | - Ali Mian
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Box 208042, Tompkins East 2, 333 Cedar St, New Haven, CT, 06520-8042, USA
| | - Rajiv Mangla
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Elias Michaelides
- Department of Surgery (Otolaryngology) and Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | | | - Dheeraj Gandhi
- Department of Radiology, University of Maryland Medical Center, Baltimore, MD, USA
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Zhou F, Yang Z, Zhu W, Chen L, Song J, Quan K, Li S, Li P, Pan Z, Liu P, Mao Y. Epidermoid cysts of the cavernous sinus: clinical features, surgical outcomes, and literature review. J Neurosurg 2017; 129:973-983. [PMID: 29271707 DOI: 10.3171/2017.6.jns163254] [Citation(s) in RCA: 9] [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] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Epidermoid cysts of the cavernous sinus (CS) are rare, and no large case series of these lesions has been reported. In this study, the authors retrospectively reviewed the outcomes of the surgical management of CS epidermoid cysts undertaken at their center and performed a review of any such cysts reported in the literature over the past 40 years. METHODS Clinical data were obtained on 31 patients with CS epidermoid cysts that had been surgically treated at the authors' hospital between 2001 and 2016. The patients' medical records, imaging data, and follow-up outcomes were retrospectively analyzed. The related literature from the past 40 years (18 articles, 20 patients) was also evaluated. RESULTS The most common chief complaints were facial numbness or hypesthesia (64.5%), absent corneal reflex (45.2%), and abducens or oculomotor nerve deficit (35.5%). On MRI, 51.6% of the epidermoid cysts showed low T1 signals and equal or high T2 signals. In the other lesions, the radiological findings varied considerably given differences in the composition of the cysts. Surgery was performed via the extradural approach (58.1%), intradural approach (32.3%), or a combined approach (9.7%). After the operation, symptoms remained similar or improved in 90.3% of patients and new oculomotor paralysis developed after the operation in 9.7% of patients. Seven patients (22.6%) developed meningitis postoperatively (5 aseptic and 2 septic), and all of them recovered. All patients achieved good recovery before discharge (Karnofsky Performance Status score ≥ 70). Over an average follow-up of 4.6 ± 3.0 years in 25 patients (80.6%), no recurrence or reoperation occurred, regardless of whether total or subtotal resection of the capsule had been achieved. CONCLUSIONS Both the extradural and intradural approaches can enable satisfactory lesion resection. A favorable prognosis and symptomatic improvement can be expected after both total and subtotal capsule resections. Total capsule resection is encouraged to minimize the possibility of recurrence provided that the resection can be safely performed.
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Affiliation(s)
- Feng Zhou
- 1Department of Neurosurgery, Huashan Hospital; and
| | - Zixiao Yang
- 1Department of Neurosurgery, Huashan Hospital; and
| | - Wei Zhu
- 1Department of Neurosurgery, Huashan Hospital; and
| | - Liang Chen
- 1Department of Neurosurgery, Huashan Hospital; and
| | | | - Kai Quan
- 1Department of Neurosurgery, Huashan Hospital; and
| | - Sichen Li
- 1Department of Neurosurgery, Huashan Hospital; and
| | - Peiliang Li
- 1Department of Neurosurgery, Huashan Hospital; and
| | - Zhiguang Pan
- 1Department of Neurosurgery, Huashan Hospital; and
| | - Peixi Liu
- 1Department of Neurosurgery, Huashan Hospital; and
| | - Ying Mao
- 1Department of Neurosurgery, Huashan Hospital; and.,2State Key Laboratory of Medical Neurobiology, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai, People's Republic of China
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Bigder MG, Helmi A, Kaufmann AM. Trigeminal neuropathy associated with an enlarging arachnoid cyst in Meckel's cave: case report, management strategy and review of the literature. Acta Neurochir (Wien) 2017; 159:2309-2312. [PMID: 28762108 DOI: 10.1007/s00701-017-3262-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 06/27/2017] [Indexed: 01/03/2023]
Abstract
We describe a rare case and novel management strategy of painful trigeminal neuropathy caused by an arachnoid cyst confined to Meckel's cave. A 57-year-old female presented with several years of progressive trigeminal pain and signs of trigeminal deafferentation, including sensory loss, corneal anesthesia and mastication muscle atrophy. Medical treatment with carbamazepine provided partial and temporary pain control. Surgical treatment was eventually performed by aspiration of the arachnoid cyst through the foramen ovale using a percutaneous approach. The patient experienced relief of pain and improvement of numbness and muscle strength. To our knowledge, this is the first case description of a percutaneous drainage of a Meckel's cave arachnoid cyst.
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Oyama K, Tahara S, Hirohata T, Ishii Y, Prevedello DM, Carrau RL, Froelich S, Teramoto A, Morita A, Matsuno A. Surgical Anatomy for the Endoscopic Endonasal Approach to the Ventrolateral Skull Base. Neurol Med Chir (Tokyo) 2017; 57:534-541. [PMID: 28845040 PMCID: PMC5638780 DOI: 10.2176/nmc.ra.2017-0039] [Citation(s) in RCA: 14] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The authors describe the surgical anatomy for the endoscopic endonasal approach (EEA) to the ventrolateral skull base. The ventrolateral skull base can be divided into two segments: the upper lateral and lower lateral skull base. The upper lateral skull base includes the cavernous sinus and the orbit, while the lower lateral skull base includes the petrous apex, Meckel's cave, parapharyngeal space, infratemporal fossa, etc. To gain access to the upper lateral skull base, a simple opening of the ethmoid sinus provides sufficient exposure of this area. To reach the lower lateral skull base, a transpterygoid approach, following ethmoidectomy, is a key procedure providing wide exposure of this area. Understanding of surgical anatomy is mandatory for treating ventrolateral skull base lesions via EEA. An appropriate, less-invasive approach should be applied depending on the size, location, and type of lesion.
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Affiliation(s)
- Kenichi Oyama
- Department of Neurosurgery, Pituitary & Endoscopic Surgery Center, Teikyo University School of Medicine
| | | | - Toshio Hirohata
- Department of Neurosurgery, Pituitary & Endoscopic Surgery Center, Teikyo University School of Medicine
| | - Yudo Ishii
- Department of Neurosurgery, Pituitary & Endoscopic Surgery Center, Teikyo University School of Medicine
| | | | - Ricardo L Carrau
- Department of Otolaryngology/Head & Neck Surgery, the Ohio State University
| | - Sebastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, Paris VII-Diderot University
| | - Akira Teramoto
- Japan Labor Health and Safety Organization, Tokyo Rosai Hospital
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School
| | - Akira Matsuno
- Department of Neurosurgery, Pituitary & Endoscopic Surgery Center, Teikyo University School of Medicine
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Raza SM, Donaldson AM, Mehta A, Tsiouris AJ, Anand VK, Schwartz TH. Surgical management of trigeminal schwannomas: defining the role for endoscopic endonasal approaches. Neurosurg Focus 2015; 37:E17. [PMID: 25270136 DOI: 10.3171/2014.7.focus14341] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Because multiple anatomical compartments are involved, the surgical management of trigeminal schwannomas requires a spectrum of cranial base approaches. The endoscopic endonasal approach to Meckel's cave provides a minimal access corridor for surgery, but few reports have assessed outcomes of the procedure or provided guidelines for case selection. METHODS A prospectively acquired database of 680 endoscopic endonasal cases was queried for trigeminal schwannoma cases. Clinical charts, radiographic images, and long-term outcomes were reviewed to determine outcome and success in removing tumor from each compartment traversed by the trigeminal nerve. RESULTS Four patients had undergone endoscopic resection of trigeminal schwannomas via the transpterygoid approach (mean follow-up 37 months). All patients had disease within Meckel's cave, and 1 patient had extension into the posterior fossa. Gross-total resection was achieved in 3 patients whose tumors were purely extracranial. One patient with combined Meckel's cave and posterior fossa tumor had complete resection of the extracranial disease and 52% resection of the posterior fossa disease. One patient with posterior fossa disease experienced a sixth cranial nerve palsy in addition to a corneal keratopathy from worsened trigeminal neuropathy. There were no CSF leaks. Over the course of the study, 1 patient with subtotal resection required subsequent stereotactic radiosurgery for disease progression within the posterior fossa. CONCLUSIONS Endoscopic endonasal approaches appear to be well suited for trigeminal schwannomas restricted to Meckel's cave and/or extracranial segments of the nerve. Lateral transcranial skull base approaches should be considered for patients with posterior fossa disease. Further multiinstitutional studies will be necessary for adequate power to help determine relative indications between endoscopic and transcranial skull base approaches.
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Affiliation(s)
- Shaan M Raza
- Department of Neurosurgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York
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