scholarly journals Endoscopic transnasal transmaxillary approach to the upper parapharyngeal space and the skull base

2019 ◽  
Vol 277 (3) ◽  
pp. 801-807
Author(s):  
Quan Liu ◽  
Huan Wang ◽  
Weidong Zhao ◽  
Xiaole Song ◽  
Xicai Sun ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Skull Base ◽  
Internal Carotid ◽  
Parapharyngeal Space ◽  
Middle Cranial Fossa ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal ◽  
Cranial Fossa ◽  
Optimal Approach

Abstract Purpose Treatment of tumors arising in the upper parapharyngeal space (PPS) or the floor of the middle cranial fossa is challenging. This study aims to present anatomical landmarks for a combined endoscopic transnasal and anterior transmaxillary approach to the upper PPS and the floor of the middle cranial fossa and to further evaluate their clinical application. Methods Dissection of the upper PPS using a combined endoscopic endonasal transpterygoid and anterior transmaxillary approach was performed in six cadaveric heads. Surgical landmarks associated with the approach were defined. The defined approach was applied in patients with tumors involving the upper PPS. Results The medial pterygoid muscle, tensor veli palatini muscle and levator veli palatini muscle were key landmarks of the approach into the upper PPS. The lateral pterygoid plate, foramen ovale and mandibular nerve were important anatomical landmarks for exposing the parapharyngeal segment of the internal carotid artery through a combined endoscopic transnasal and anterior transmaxillary approach. The combined approach provided a better view of the upper PPS and middle skull base, allowing for effective bimanual techniques and bleeding control. Application of the anterior transmaxillary approach also provided a better view of the inferior limits of the upper PPS and facilitated control of the internal carotid artery. Conclusions Improving the knowledge of the endoscopic anatomy of the upper PPS allowed us to achieve an optimal approach to tumors arising in the upper PPS. The combined endoscopic transnasal and anterior transmaxillary approach is a minimally invasive alternative approach to the upper PPS.

scholarly journals REMOVING A RETROSELLAR PITUITARY ADENOMA VIA THE ENDOSCOPIC ENDONASAL TRANSSPHENOIDAL TRANSCAVERNOUS APPROACH

2019 ◽  
Vol 21 (2) ◽  
pp. 39-44
Author(s):  
О. I. Sharipov ◽  
M. A. Kutin ◽  
P. L. Kalinin
Keyword(s):  
Pituitary Adenoma ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cavernous Sinus ◽  
Internal Carotid ◽  
Sella Turcica ◽  
Posterior Cranial Fossa ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal ◽  
Cranial Fossa

The study objective is to describe the removal of the pituitary adenoma from the posterior cranial fossa through endoscopic transsphenoidal trans-cavernous approach, when the main surgical corridor was the tumor-intact cavernous sinus. Materials and methods. A 55-year-old male patient with endosupraretrosellar endocrine-inactive pituitary adenoma was admitted to N.N. Burdenko Research Center of Neurosurgery. The patient had earlier undergone two surgeries for pituitary adenoma. Using the endoscopic endonasal transsphenoidal approach, we found that these surgeries resulted in the formation of scar-altered adipose tissue in the sphenoid sinus and partly in the sella turcica; anatomical landmarks indicating the midline and the location of the internal carotid arteries were absent. We formed an access to both retro- and suprasellar portions of the tumor between the sella turcica and cavernous segment of the internal carotid artery (through the cavernous sinus); then we dissected anterior and posterior walls of the sinus and revealed a soft capsule-free pituitary adenoma, which was completely removed by a vacuum aspirator. The skull base defect was repaired using the multilayer technique with autologous tissues. Results. After surgery, neurological status and visual functions did not change. In the postoperative period, we observed no oculomotor disorders, pituitary insufficiency, diabetes insipidus, or nasal liquorrhea. Follow-up computed tomography scans revealed no signs of intracranial complications or obvious residual tumor tissue. Magnetic resonance imaging 4 month postoperatively demonstrated small laterosellar fragments of the tumor in the sella turcica. The patient was further followed up. Conclusion. Cavernous sinus is a natural anatomical corridor providing access to the structures of the posterior cranial fossa and interpeduncular cistern. The main risk (damage to the cavernous segment of the internal carotid artery) can be minimized by using intraoperative dopplerography and visual control of all manipulations.

Nasopharyngeal muscle patch for the management of internal carotid artery injury in endoscopic endonasal surgery

2020 ◽  
Vol 133 (5) ◽  
pp. 1382-1387 ◽  
Author(s):  
Wei-Hsin Wang ◽  
Stefan Lieber ◽  
Ming-Ying Lan ◽  
Eric W. Wang ◽  
Juan C. Fernandez-Miranda ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Skull Base ◽  
Internal Carotid ◽  
Skull Base Surgery ◽  
Management Technique ◽  
Endoscopic Endonasal Surgery ◽  
Endonasal Surgery ◽  
Endoscopic Endonasal ◽  
Muscle Graft

OBJECTIVEInjury to the internal carotid artery (ICA) is the most critical complication of endoscopic endonasal skull base surgery. Packing with a crushed muscle graft at the injury site has been an effective management technique to control bleeding without ICA sacrifice. Obtaining the muscle graft has typically required access to another surgical site, however. To address this concern, the authors investigated the application of an endonasally harvested longus capitis muscle patch for the management of ICA injury.METHODSOne colored silicone-injected anatomical specimen was dissected to replicate the surgical access to the nasopharynx and the stepwise dissection of the longus capitis muscle in the nasopharynx. Two representative cases were selected to illustrate the application of the longus capitis muscle patch and the relevance of clinical considerations.RESULTSA suitable muscle graft from the longus capitis muscle could be easily and quickly harvested during endoscopic endonasal skull base surgery. In the illustrative cases, the longus capitis muscle patch was successfully used for secondary prevention of pseudoaneurysm formation following primary bleeding control on the site of ICA injury.CONCLUSIONSNasopharyngeal harvest of a longus capitis muscle graft is a safe and practical method to manage ICA injury during endoscopic endonasal surgery.

The So-Called Cavernous Sinus: A Review of the Controversy and Its Implications for Neurosurgeons

Neurosurgery ◽  
1982 ◽  
Vol 11 (5) ◽  
pp. 712-717 ◽  
Author(s):  
John N. Taptas
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cavernous Sinus ◽  
Internal Carotid ◽  
Cranial Nerves ◽  
Sella Turcica ◽  
Middle Cranial Fossa ◽  
Cranial Fossa ◽  
Base Of The Skull ◽  
Extradural Space

Abstract The so-called cavernous sinus is a venous pathway, an irregular network of veins that is part of the extradural venous network of the base of the skull, not a trabeculated venous channel. This venous pathway, the internal carotid artery, and the oculomotor cranial nerves cross the medial portion of the middle cranial fossa in an extradural space formed on each side of the sella turcica by the diverging aspects of a dural fold. In this space the venous pathway has only neighborhood relations with the internal carotid artery and the cranial nerves. The space itself must be distinguished from the vascular and nervous elements that it contains. The revision of the anatomy of this region has not only theoretical interest but also important clinical implications.

Radiographic Analysis of the Vidian Canal and Its Utility in Petrous Internal Carotid Artery Localization

2018 ◽  
Vol 15 (5) ◽  
pp. 577-583 ◽  
Author(s):  
Eric C Mason ◽  
Patricia A Hudgins ◽  
Gustavo Pradilla ◽  
Nelson M Oyesiku ◽  
C Arturo Solares
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Skull Base ◽  
Internal Carotid ◽  
Expert Knowledge ◽  
Average Distance ◽  
Surgical Approaches ◽  
Endoscopic Endonasal ◽  
Computed Tomographic ◽  
Vidian Canal

Abstract BACKGROUND Endoscopic endonasal surgery of the skull base requires expert knowledge of the anatomy and a systematic approach. The vidian canal is regarded as a reliable landmark to localize the petrous internal carotid artery (pICA) near the second genu, which can be used for orientation in deep skull base approaches. There is controversy about the relationship between the vidian canal and the pICA. OBJECTIVE To further establish the vertical relationship between the vidian canal and the pICA to aid in surgical approaches to the skull base. METHODS We utilized a collection of institutional review board-approved computed tomographic (CT) angiograms (CTAs). Fifty CTAs were studied bilaterally for 100 total sides. The vidian canal was visualized radiographically to determine whether it terminates below, at, or above the level of the pICA. RESULTS Sixty-six of 100 vidian canals terminated inferior to the pICA (66%), which was the most common relationship observed. The average distance inferior to the pICA was 1.01 mm on the right, 1.18 mm on the left, and 1.09 mm of the total 66 sides. Less commonly, the vidian canal terminated at the level of the pICA canal in 34 sides (34%). The vidian canal was not observed to terminate superior to the pICA in any of the 50 CTAs studied. CONCLUSION The vidian canal terminates inferior to the pICA most commonly, but often terminates at the level of the pICA. Careful drilling clockwise inferior to superior around the vidian canal should allow for safe pICA localization in most cases.

scholarly journals Morphometry of Glasscock’s Triangle Pertinent to the Exposure of Horizontal Intrapetrosal Segment of the Internal Carotid Artery

2019 ◽  
Vol 08 (03) ◽  
pp. 093-096
Author(s):  
Abu Ubaida Siddiqui ◽  
Richa Gurudiwan ◽  
Abu Talha Siddiqui ◽  
Nikita Chaudhary ◽  
Meryl Rachel John ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Surface Area ◽  
Racial Differences ◽  
Internal Carotid ◽  
Cranial Nerves ◽  
Middle Cranial Fossa ◽  
Surgical Interventions ◽  
Cadaveric Specimen ◽  
Cranial Fossa

Abstract Background and Aim The specific anatomical triangles around the cavernous sinus are frequently explored areas in neurosurgeries and thus require a methodical approach keeping in mind the possibility of variational anatomy and morphometric differences. One of the most inconsistent triangles is the Glasscock’s (posterolateral) triangle (GT) in the middle cranial fossa. Materials and Methods The present study was undertaken on 26 skull bases of the middle cranial fossa from cadavers and 42 dry adult skulls from the departmental collection to analyze parameters of the GT pertinent to the horizontal intrapetrosal segment of the internal carotid artery. The measurements of all sides of the GT were done and the mean surface area was calculated using Heron’s formula. The findings of the study were compared with earlier works where other methods of investigation were employed, such as, dry bones/computed tomography scans, cadaveric studies. Observations The GT in the present study had a mean surface area of 43 mm2. The study presented with variable morphological and morphometric data as compared with earlier studies. The scientific attribute to the differences in parameters is presumably relevant to the racial differences as well as the pathophysiological condition of the subject. Conclusions Surgical interventions to the base of the skull have evolved enormously over the years. Earlier studies have described the triangle on cadaveric specimen. We have attempted to revisit the area in cadaveric as well as dry skull base. Flawless information of the area under surgery augments safer procedures and reduction in the damage to brain tissue as well as the cranial nerves. The putative clinical implications of the present study are useful in helping in high precision surgeries and enhanced patient care. The highly variable GT needs to be understood properly for a desired culmination in ICA exposure in the intrapetrosal segment.

scholarly journals Clival chordomas: considerations after 16 years of endoscopic endonasal surgery

2018 ◽  
Vol 128 (2) ◽  
pp. 329-338 ◽  
Author(s):  
Matteo Zoli ◽  
Laura Milanese ◽  
Rocco Bonfatti ◽  
Marco Faustini-Fustini ◽  
Gianluca Marucci ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Survival Rate ◽  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Skull Base ◽  
Internal Carotid ◽  
Neurological Deficits ◽  
Tumor Removal ◽  
Endoscopic Endonasal

OBJECTIVEIn the past decade, the role of the endoscopic endonasal approach (EEA) has relevantly evolved for skull base tumors. In this study, the authors review their surgical experience with using an EEA in the treatment of clival chordomas, which are deep and infiltrative skull base lesions, and they highlight the advantages and limitations of this ventral approach.METHODSAll consecutive cases of chordoma treated with an EEA between 1998 and 2015 at a single institution are included in this study. Preoperative assessment consisted of neuroimaging (MRI and CT with angiography sequences) and endocrinological, neurological, and ophthalmological evaluations, which were repeated 3 months after surgery and annually thereafter. Postoperative adjuvant therapies were considered.RESULTSSixty-five patients (male/female ratio 1:0.9) were included in this study. The median age was 48 years (range 9–80 years). Gross-total resection (GTR) was achieved in 47 cases (58.7%). On univariate analysis, primary procedures (p = 0.001), location in the superior or middle third of the clivus (p = 0.043), extradural location (p = 0.035), and histology of conventional chordomas (p = 0.013) were associated with a higher rate of GTR. The complication rate was 15.1%, and there were no perioperative deaths. Most complications did not result in permanent sequelae and included 2 CSF leaks (2.5%), 5 transient cranial nerve VI palsies (6.2%), and 2 internal carotid artery injuries (2.5%), which were treated with coil occlusion of the internal carotid artery without neurological deficits. Three patients (3.8%) presented with complications resulting in permanent neurological deficits due to a postoperative hematoma (1.2%) causing a hemiparesis, and 2 permanent ophthalmoplegias (2.5%). Seventeen patients (26.2%) have died of tumor progression over the course of follow-up (median 52 months, range 7–159 months). Based on Kaplan-Meier analysis, the survival rate was 77% at 5 years and 57% at 10 years. On multivariate analysis, the extent of tumor removal (p = 0.001) and the absence of previous treatments (p = 0.001) proved to be correlated with a longer survival rate.CONCLUSIONSThe EEA was associated with a high rate of tumor removal and symptom control, with low morbidity and preservation of a good quality of life. These results allow for a satisfactory overall survival rate, particularly after GTR and for primary surgery. Considering these results, the authors believe that an EEA can be a helpful tool in chordoma surgery, achieving a good balance between as much tumor removal as possible and the preservation of an acceptable patient quality of life.

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