Syphilitic Gumma Lesion in Meckel's Cave and Infratemporal Fossa Presenting with Cranial Nerve Deficit

Abstract OBJECTIVE: The authors present a report of a solitary fibrous tumor (SFT) arising from the intradural component of the VIth cranial nerve as it travels through the prepontine cistern. SFTs of the central nervous system are extremely rare entities that clinically masquerade as dural-based lesions, such as meningiomas or hemangiopericytomas. Because of their infrequency and clinical similarity to other central nervous system (CNS) lesions, diagnosis is largely dependent on pathological features. In this study, the authors define a subpopulation of SFTs that seem to arise directly from nerve, rather than meninges, and clinically mimic the appearance of a schwannoma. CLINICAL PRESENTATION: The patient was a 29-year-old woman with a several-month history of progressive right arm and leg numbness and mild hemiparesis, with the development of diplopia 2 weeks before admission. Outside imaging revealed a 3.9-cm mass in the prepontine cistern with extension into Meckel's cave and the cavernous sinus, resulting in significant brainstem compression. INTERVENTION: The patient underwent preoperative angiography with embolization of feeding vessels off of the left meningohypophyseal trunk. The patient was then taken to the operating room by a combined neurosurgical and ear, nose, and throat team, where the patient underwent a retrolabyrinthine/subtemporal craniotomy for tumor resection. During resection of the prepontine component, the tumor was identified as originating from the left Cranial Nerve VI as it traversed through the prepontine cistern. Resection of the tumor component involving the cavernous sinus and Meckel's cave was deferred for follow-up treatment with intensity-modulated radiation therapy. Pathological examination revealed tissue consistent with the diagnosis of SFT. CONCLUSION: SFTs involving the CNS are rare entities that are almost always diagnosed after tissue is obtained because of their clinical and radiographic similarity to meningiomas. This patient had an SFT masquerading as a VIth cranial nerve schwannoma. Although the natural history of SFTs in the CNS is not completely understood, correct diagnosis is important, given the rate of recurrence found in the more common pleural-based SFT and examples of CNS SFTs with malignant features.

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Extended middle fossa approach with anterior petrosectomy for resection of upper petroclival meningioma involving Meckel’s cave: operative video and technical nuances

Neurosurgical FOCUS ◽

10.3171/2017.10.focusvid.17345 ◽

2017 ◽

Vol 43 (videosuppl2) ◽

pp. V8 ◽

Cited By ~ 2

Author(s):

James K. Liu

Keyword(s):

Surgical Management ◽

Cranial Nerve ◽

Cranial Nerves ◽

Middle Fossa ◽

Meckel’S Cave ◽

Petroclival Meningioma ◽

Middle Fossa Approach ◽

Petroclival Meningiomas ◽

Meckel's Cave ◽

Anterior Petrosectomy

The surgical management of petroclival meningiomas remains a formidable challenge. These tumors are deep in the base of the skull and arise medial to the fifth cranial nerve. In this operative video, the author demonstrates the extended middle fossa approach with anterior petrosectomy to resect an upper petroclival meningioma extending into Meckel’s cave with brainstem compression. This approach is very useful for accessing deep tumors located above and below the tentorium, and between the fifth and seventh cranial nerves. Access to Meckel’s cave is readily achieved by opening the fibrous ring of the porous trigeminus. This video demonstrates the operative technique and surgical nuances of the skull base approach, useful anatomic landmarks of the middle fossa rhomboid for safe petrosectomy drilling, pearls for cranial nerve and neuro-otologic preservation, and exposure of Meckel’s cave. A gross-total resection was achieved, and the patient was neurologically intact. In summary, the extended middle fossa approach with anterior petrosectomy is an important strategy in the armamentarium for surgical management of petroclival meningiomas.The video can be found here: https://youtu.be/jttwJIYPHC8.

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Lesions in Meckel's cave: variable presentation and pathology

Journal of Neurosurgery ◽

10.3171/jns.1987.67.5.0684 ◽

1987 ◽

Vol 67 (5) ◽

pp. 684-689 ◽

Cited By ~ 44

Author(s):

David W. Beck ◽

Arnold H. Menezes

Keyword(s):

Cranial Nerve ◽

Neurological Deficits ◽

Resonance Imaging ◽

Total Removal ◽

Postoperative Results ◽

Meckel’S Cave ◽

Content Type ◽

Meckel's Cave ◽

Mass Lesions ◽

Variable Presentation

✓ A series of 12 patients with mass lesions arising from Meckel's cave is presented. Patients' age on presentation ranged from 13 months to 71 years. Nine of the 12 patients had symptoms referable to the fifth cranial nerve, but only three complained of facial pain. The 12 patients presented eight different pathological entities, including meningioma, lipoma, schwannoma, malignant melanotic schwannoma, arachnoid cyst, neurofibroma, epidermoid tumor, and chordoma. Computerized tomography and magnetic resonance imaging were most useful in localizing the lesion to Meckel's cave. All 12 patients underwent a subtemporal approach to the lesion, and gross total removal was achieved in 11. Postoperative results were excellent with no increased neurological deficits seen 3 months postoperatively. Most patients had resolution of the cranial nerve deficits except for fifth nerve function, which was impaired in nine patients postoperatively. This series demonstrates that lesions in Meckel's cave can have a varied and unusual presentation, as well as an assortment of pathology. Total removal of lesions in this area resulted in relief of symptoms in most patients, with minimum morbidity.

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Endoscopic anterior transmaxillary “transalisphenoid” approach to Meckel’s cave and the middle cranial fossa: an anatomical study and clinical application

Journal of Neurosurgery ◽

10.3171/2017.8.jns171308 ◽

2018 ◽

Vol 130 (1) ◽

pp. 227-237 ◽

Cited By ~ 9

Author(s):

Huy Q. Truong ◽

Xicai Sun ◽

Emrah Celtikci ◽

Hamid Borghei-Razavi ◽

Eric W. Wang ◽

...

Keyword(s):

Maxillary Sinus ◽

Cavernous Sinus ◽

Infratemporal Fossa ◽

Middle Cranial Fossa ◽

Anatomical Landmarks ◽

Middle Fossa ◽

Meckel’S Cave ◽

Meckel's Cave ◽

Cranial Fossa ◽

Greater Wing

OBJECTIVEMultiple 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.METHODSEndoscopic 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.RESULTSThe 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.CONCLUSIONSThe 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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26 Transpterygoid Approaches to the Infratemporal Fossa and Meckel’s Cave

Endoscopic Sinonasal Dissection Guide ◽

10.1055/b-0037-145189 ◽

2017 ◽

Keyword(s):

Infratemporal Fossa ◽

Meckel’S Cave ◽

Meckel's Cave

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Endoscopic-Assisted Microsurgical Resection of Right Recurrent Meckel's Cave Meningioma Extended to Cavernous Sinus

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1725934 ◽

2021 ◽

Author(s):

Arianna Fava ◽

Paolo di Russo ◽

Lorenzo Giammattei ◽

Sébastien Froelich

Keyword(s):

Skull Base ◽

Cavernous Sinus ◽

Infratemporal Fossa ◽

Tumor Resection ◽

Lateral Wall ◽

Complete Removal ◽

Meckel’S Cave ◽

Large Tumor ◽

Postoperative Mri ◽

Meckel's Cave

Abstract Objective This study was aimed to present the complete removal of a large recurrent Meckel's cave meningioma. Design This study is a case report. Setting The study was conducted at Department of Neurosurgery and Skull Base Laboratory at Lariboisiére Hospital, Paris. Participant A 53-year-old male was presented with a severe V1, V2, and V3 hypoesthesia and pain. He was operated 7 years ago for a right Meckel's cave meningioma with postoperative V1–V2 hypoesthesia. Magnetic resonance imaging (MRI) showed a large tumor recurrence extending into the cavernous sinus (CS), posterior fossa (PF), sphenoid sinus (SS), pterygopalatine (PPF), and infratemporal fossa (ITF; Fig. 1). Main Outcome Measures Radiological results and postoperative course were assessed for this study. Results The previous right frontotemporal approach was used. The lateral wall of the orbit, the middle fossa floor and the anterior temporal base were drilled to expose the orbit, PPF, and ITF. Foramen ovale (FO), foramen rotondum (FR), and superior orbital fissure (SOF) were opened. The meningoorbital band was cut and the lateral wall of CS was elevated (Fig. 2). The inferior orbital fissure was opened and tumor removed into the ITF, PPF, and orbit. After entering Meckel's cave from above, tumor was removed from PF. After microsurgical tumor removal, a 45-degree endoscope was used to remove tumor remnant and mucosa into SS. A watertight dural closure with pericranium was performed, reinforced with autologous fat and fibrin glue. Postoperative MRI showed complete tumor resection (Fig. 1). The patient experienced a right-side keratitis that resolved within 10 days and a V3 hypoesthesia that improved at 2 months. Conclusion This surgical case shows how the anatomical knowledge is mandatory in skull base surgery and how the integration of microsurgical and endoscopic-assisted techniques allows to obtain optimal results.The link to the video can be found at: https://youtu.be/qxt_389AdWU.

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The Endoscopic Endonasal Transmaxillary Approach to Meckel's Cave Through the Inferior Orbital Fissure

Operative Neurosurgery ◽

10.1093/ons/opx009 ◽

2017 ◽

Vol 13 (3) ◽

pp. 367-373 ◽

Cited By ~ 2

Author(s):

Xin Zhang ◽

Halima Tabani ◽

Ivan El-Sayed ◽

Matthew Russell ◽

Xuequan Feng ◽

...

Keyword(s):

Infratemporal Fossa ◽

Middle Cranial Fossa ◽

Nasolacrimal Duct ◽

Neurovascular Bundle ◽

Infraorbital Nerve ◽

Meckel’S Cave ◽

Endoscopic Endonasal ◽

Maxillary Nerve ◽

Surgical Access ◽

Meckel's Cave

Abstract BACKGROUND: Surgical access to Meckel's Cave (MC) is challenging due to its deep location and surrounding important neurovascular structures. Currently existing endoscopic endonasal (EE) approaches require dissecting near the internal carotid artery (ICA) or require transposition of the pterygopalatine neurovascular bundle. OBJECTIVE: To describe a novel approach to access the anterolateral aspect of the MC using a minimally invasive EE route. METHODS: The EE transmaxillary transinferior orbital fissure approach was simulated in 10 specimens. The approach included an ethmoidectomy followed by an extended medial maxillectomy with transposition of the nasolacrimal duct. The infraorbital fissure was opened, and the infraorbital neurovascular bundle was transposed inferiorly. A quadrilateral space, bound by the maxillary nerve inferomedially, ophthalmic nerve superomedially, infraorbital nerve inferolaterally, and floor of the orbit superolaterally, was exposed. The distances from the foramen rotundum (FR) to the ICA, orbital apex (OA), and infratemporal crest (ITC) and from the OA to the ICA and ITC were measured. RESULTS: The distances obtained were FR-ICA = 19.42 ± 2.03 mm, FR-ITC = 18.76 ± 1.75 mm, FR-OA = 8.54 ± 1.34 mm, OA-ITC = 19.78 ± 2.63 mm, and OA-ICA = 20.64 ± 142 mm. Two imaginary lines defining safety boundaries were observed between the paraclival ICA and OA, and between the OA and ITC (safety lines 1 and 2). CONCLUSION: The reported approach provides a less invasive route compared to contemporary approaches, allowing expanded views and manipulation anteromedial and anterolateral to MC. It may be safer than the existing approaches as it does not require transposition of the ICA, infratemporal fossa, and pterygopalatine fossa, and allows access to tumors located anteriorly on the floor of the middle cranial fossa.

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