scholarly journals Microsurgical Resection of Multiple Giant Glomus Tumors

2019 ◽  
Vol 80 (S 04) ◽  
pp. S385-S388
Author(s):  
Guilherme H. W. Ceccato ◽  
Marcio S. Rassi ◽  
Luis A. B. Borba
Keyword(s):  
Carotid Artery ◽  
Facial Paralysis ◽  
Voice Quality ◽  
Cranial Nerves ◽  
Internal Auditory Canal ◽  
Mass Effect ◽  
Jugular Foramen ◽  
Surgical Approaches ◽  
Glomus Tumors ◽  
Complex Anatomy

AbstractGlomus tumors, also called paragangliomas, are challenging lesions, demanding accurate knowledge of complex anatomy and pertinent approaches. We present the case of a 39-year-old male presenting with headache, vertigo, tinnitus, hearing loss, and hoarseness. Neurological assessment showed facial paralysis House–Brackmann IV and lower cranial nerves deficits. Preoperative magnetic resonance imaging (MRI) demonstrated two large lesions, suggestive of a glomus jugulare, and carotid body paragangliomas. Considering worsening of the symptoms and the important mass effect of both lesions over the neurovascular structures, microsurgical excision was offered, after preoperative tumor embolization. We preferred to approach both lesions in the same operation, starting by the cervical tumor. Initially there was not an easily identifiable dissection plane between the tumor and the carotid artery, but it was achieved after performing a subadventitial dissection, being possible to resect the entire lesion. The jugular foramen lesion was approached through a postauricular transtemporal approach, skeletonizing the sigmoid sinus, jugular bulb, and facial nerve, following a complete mastoidectomy. The tumor, extending to the intradural compartment, middle ear, internal auditory canal, petrous internal carotid artery, and internal jugular vein was completely removed. Postoperative MRI demonstrated complete resection of both lesions, and pathology confirmed to be paragangliomas. In the immediate postoperative period, the facial paralysis evolved to House–Brackmann grade VI, improving to grade III during follow-up. The patient underwent a vocal cord medialization in order to improve voice quality and swallowing. These are challenging lesions and extensive laboratory training is mandatory to be familiarized with the regional anatomy and its various surgical approaches.The link to the video can be found at: https://youtu.be/gA_ckwFq_9c.

Jugular Foramen: Microscopic Anatomic Features and Implications for Neural Preservation with Reference to Glomus Tumors Involving the Temporal Bone

Neurosurgery ◽  
2001 ◽  
Vol 48 (4) ◽  
pp. 838-848 ◽  
Author(s):  
Chandranath Sen ◽  
Karin Hague ◽  
Rajneesh Kacchara ◽  
Arthur Jenkins ◽  
Sumit Das ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Connective Tissue ◽  
Internal Carotid Artery ◽  
Temporal Bone ◽  
Cranial Nerve ◽  
Internal Carotid ◽  
Cranial Nerves ◽  
Jugular Foramen ◽  
Jugular Bulb ◽  
Glomus Tumors

Abstract OBJECTIVE Our goals were to study the normal histological features of the jugular foramen, compare them with the histopathological features of glomus tumors involving the temporal bone, and thus provide insight into the surgical management of these tumors with respect to cranial nerve function. METHODS Ten jugular foramen blocks were obtained from five human cadavers after removal of the brain. Microscopic studies of these blocks were performed, with particular attention to fibrous or bony compartmentalization of the jugular foramen, the relationships of the caudal cranial nerves to the jugular bulb/jugular vein and internal carotid artery, and the fascicular structures of the nerves. In addition, we studied the histopathological features of 11 glomus tumors involving the temporal bone (10 patients), with respect to nerve invasion, associated fibrosis, and carotid artery adventitial invasion. RESULTS A dural septum separating the IXth cranial nerve from the fascicles of Cranial Nerves X and XI, at the intracranial opening, was noted. Only two specimens, however, had a septum (one bony and one fibrous) producing internal compartmentalization of the jugular foramen. The cranial nerves remained fasciculated within the foramen, with the vagus nerve containing multiple fascicles and the glossopharyngeal and accessory nerves containing one and two fascicles, respectively. All of these nerve fascicles lay medial to the superior jugular bulb, with the IXth cranial nerve located anteriorly and the XIth cranial nerve posteriorly. All nerve fascicles had separate connective tissue sheaths. A dense connective tissue sheath was always present between the IXth cranial nerve and the internal carotid artery, at the level of the carotid canal. The inferior petrosal sinus was present between the IXth and Xth cranial nerves, as single or multiple venous channels. The glomus tumors infiltrated between the cranial nerve fascicles and inside the perineurium. They also produced reactive fibrosis. In one patient, in whom the internal carotid artery was also excised, the tumor invaded the adventitia. CONCLUSION Within the jugular foramen, the cranial nerves lie anteromedial to the jugular bulb and maintain a multifascicular histoarchitecture (particularly the Xth cranial nerve). Glomus tumors of the temporal bone can invade the cranial nerve fascicles, and infiltration of these nerves can occur despite normal function. In these situations, total resection may not be possible without sacrifice of these nerves.

Microsurgical Resection of Recurrent Cavernous Sinus Hemangioma by Superior and Lateral Approach: 2-Dimensional Operative Video

2019 ◽  
Vol 19 (2) ◽  
pp. E165-E166
Author(s):  
Qazi Zeeshan ◽  
Juan P Carrasco Hernandez ◽  
Michael K Moore ◽  
Laligam N Sekhar
Keyword(s):  
Optic Nerve ◽  
Carotid Artery ◽  
Cavernous Sinus ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Brain Magnetic Resonance Imaging ◽  
Mass Effect ◽  
Lateral Approach ◽  
Microsurgical Resection ◽  
The Right

Abstract This video shows the technical nuances of microsurgical resection of recurrent cavernous sinus (CS) hemangioma by superior and lateral approach.  A 77-yr-old woman presented with headache and difficulty in vision in right eye for 6 mo. She had previously undergone attempted resection of a right CS tumor in another hospital with partial removal, and the tumor had grown significantly. Neurological examination revealed proptosis, cranial nerve 3 palsy, and loss of vision in right eye (20/200). Left side visual acuity was 20/20.  Brain magnetic resonance imaging (MRI) demonstrated a large CS mass with homogeneous enhancement, measuring 3.3 × 3.3 × 2.6 cm, extending into the suprasellar cistern with mass effect on the right optic nerve. It extended anteriorly to the region of the right orbital apex and abuted the basilar artery posteriorly.  She underwent right frontotemporal craniotomy, posterolateral orbitotomy and anterior clinoidectomy as well as optic nerve decompression, and the CS tumor was removed by superior and lateral approach. An incision was made into the superior wall of the CS medial to the third nerve. On lateral aspect the tumor had extended outside the CS through the Parkinson's triangle. Posteriorly it extended through the clival dura. Anteriorly tumor encased the carotid artery and it was gradually dissected away. At the end of the operation, all of the cranial nerves were intact.  Postoperative MRI showed near complete tumor resection with preservation of the internal carotid artery. At 6 mo follow-up her modified Rankin Scale was 1 and vision in left eye was normal.  Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

Three-dimensional Computed Tomographic Cranial Base Measurements for Improvement of Surgical Approaches to the Petrous Carotid Artery and Apex Regions

Neurosurgery ◽  
2001 ◽  
Vol 49 (2) ◽  
pp. 342-353 ◽  
Author(s):  
Alan T. Villavicencio ◽  
Jean-Christophe Leveque ◽  
Ketan R. Bulsara ◽  
Allan H. Friedman ◽  
Linda Gray
Keyword(s):  
Computed Tomography ◽  
Carotid Artery ◽  
Three Dimensional ◽  
Internal Auditory Canal ◽  
Cranial Base ◽  
Petrous Apex ◽  
Surgical Approaches ◽  
Tomographic Images ◽  
Computed Tomographic ◽  
Preoperative Information

Abstract OBJECTIVE The bony and vascular anatomic features in the region of the petrous apex can vary significantly. These variations affect the operative view obtained via extended subtemporal or anterior transpetrosal approaches to cranial base lesions for individual patients. The goal of this study was to evaluate three-dimensional computed tomography as a means of obtaining detailed preoperative anatomic information regarding bony and vascular landmarks and spatial relationships in the region of the petrous carotid artery and petrous apex. METHODS We radiographically studied 15 patients (30 sides), using 0.8- to 1-mm-thick, reconstructed, computed tomographic images. Special attention was given to the course of the petrous carotid artery. RESULTS The petrous carotid artery was located lateral to the trigeminal impression. The size of the petrous apex medial to the horizontal petrous carotid artery was observed to be variable. The width of bone from the trigeminal impression to the wall of the internal auditory canal averaged 9.6 mm (range, 5.2–16.1 mm). A variable amount of bone overlying the internal auditory canal (4.5 mm) was also present. Multiple other relationships among key landmarks were quantified. CONCLUSION There is significant variability in the anatomic features of the petrous apex among patients. For each patient, detailed preoperative information regarding the amount of bone to be removed during a cranial base procedure can be obtained using three-dimensional computed tomography. This information may be critical for determination of the amount of extra exposure that can be achieved via an anterior petrosectomy for each patient.

Microsurgical and Endoscopic Anatomy of the Extended Retrosigmoid Inframeatal Infratemporal Approach

2015 ◽  
Vol 11 (1) ◽  
pp. 181-189 ◽  
Author(s):  
Roberto Colasanti ◽  
Al-Rahim A Tailor ◽  
Mehrnoush Gorjian ◽  
Jun Zhang ◽  
Mario Ammirati
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Infratemporal Fossa ◽  
Cranial Nerves ◽  
Jugular Foramen ◽  
Sigmoid Sinus ◽  
Mean Width ◽  
Infratemporal Approach ◽  
Cervical Internal Carotid Artery

AbstractBACKGROUNDDifferent and often complex routes are available to deal with jugular foramen tumors with extracranial extension.OBJECTIVETo describe a novel extension of the retrosigmoid approach useful to expose the extracranial area abutting the posterior fossa skull base.METHODSA navigation-guided, endoscope-assisted retrosigmoid inframeatal approach was performed on 6 cadaveric heads in the semisitting position, displaying an area from the internal acoustic meatus to the lower cranial nerves and exposing the intrapetrous internal carotid artery. We then continued removing the temporal bone located between the sigmoid sinus and the hearing apparatus, reaching the infratemporal area just lateral to the jugular fossa. This drilling, which we refer to as posterolateral inframeatal drilling, has not previously been described. Drilling of the horizontal segment of the occipital squama allowed good visualization of the uppermost cervical internal carotid artery, internal jugular vein, and lower extracranial cranial nerves.RESULTSWe were able to provide excellent exposure of the inframeatal area and of the posterior infratemporal fossa from different operative angles, preserving the neurovascular structures and the labyrinth in all specimens. The intradural operative window on the extracranial compartment was limited by the venous sinuses and the hearing apparatus and presented a mean width of 8.52 mm. Sigmoid sinus transection led to better visualization of the lateral half of the jugular foramen and of the uppermost cervical internal carotid artery.CONCLUSIONThe navigation-guided endoscope-assisted extended retrosigmoid inframeatal infratemporal approach provides an efficient and versatile route for resection of jugular foramen tumors with extracranial extension.

scholarly journals Endoscopic endonasal translacerum approach to the inferior petrous apex

2016 ◽  
Vol 124 (4) ◽  
pp. 1032-1038 ◽  
Author(s):  
Masaaki Taniguchi ◽  
Nobuyuki Akutsu ◽  
Katsu Mizukawa ◽  
Masaaki Kohta ◽  
Hidehito Kimura ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Surgical Simulation ◽  
Internal Auditory Canal ◽  
Jugular Foramen ◽  
Petrous Apex ◽  
Partial Removal ◽  
Endoscopic Endonasal ◽  
Anatomical Features ◽  
Petrous Portion ◽  
Sufficient Space

OBJECT The surgical approach to lesions involving the inferior petrous apex (IPA) is still challenging. The purpose of this study is to demonstrate the anatomical features of the IPA and to assess the applicability of an endoscopic endonasal approach through the foramen lacerum (translacerum approach) to the IPA. METHODS The surgical simulation of the endoscopic endonasal translacerum approach was conducted in 3 cadaver heads. The same technique was applied in 4 patients harboring tumors involving the IPA (3 chordomas and 1 chondro-sarcoma). RESULTS By removing the fibrocartilaginous component of the foramen lacerum, a triangular space was created between the anterior genu of the petrous portion of the carotid artery and the eustachian tube, through which the IPA could be approached. The range of the surgical maneuver reached laterally up to the internal auditory canal, jugular foramen, and posterior vertical segment of the petrous portion of the carotid artery. In clinical application, the translacerum approach provided sufficient space to handle tumors at the IPA. Gross-total and partial removal was achieved in 3 and 1 cases, respectively, without permanent surgery-related morbidity and mortality. CONCLUSIONS The endoscopic endonasal translacerum approach provides reliable access to the IPA. It is indicated alone for lesions confined to the IPA and in combination with other approaches for more extensive lesions.

scholarly journals Internal Auditory Canal Reconstruction After Vestibular Schwannomas Removal Through Retrosigmoid-Transmeatal Approach

2018 ◽  
Vol 26 (3) ◽  
pp. 237-241
Author(s):  
Ricardo Ramina ◽  
Gustavo Simiano Jung ◽  
Erasmo Barros Da Silva Jr ◽  
Guilherme José Agnoletto ◽  
Luis Fernando Moura Da Silva Jr ◽  
...  
Keyword(s):  
Cranial Nerves ◽  
Internal Auditory Canal ◽  
Jugular Foramen ◽  
Vestibular Schwannomas ◽  
Fat Tissue ◽  
Resonance Imaging ◽  
Tumor Removal ◽  
Postoperative Mri ◽  
Csf Leakage ◽  
Magnetic Resonance Imaging Mri

Objectives: To present a technique of internal auditory canal (IAC) reconstruction using a pediculated dural flap, after removal of vestibular schwannomas through the retrosigmoid craniotomy. Methods: From a series of 213 patients with vestibular schwannomas operated between January 2008 and March 2016 through the retrosigmoid-transmeatal approach, 183 underwent reconstruction of the internal auditory canal with a pediculated dural flap. The IAC was drilled towards the fundus preserving the labyrinthine structures. The dura mater over the IAC was dissected from the bone, remaining pediculated at the entrance of the jugular foramen. This dural flap was used to cover the cranial nerves inside the IAC after tumor removal. Opened mastoid cells and the IAC were closed with muscle or fat grafts and fibrin glue. Results: Reconstruction of the IAC using the described technique was possible in in 183 cases. Fifteen patients (6.8%) developed postoperative cerebrospinal fluid (CSF) leakage and seven patients required reoperation (3.2%) to close the fistulae. Postoperative magnetic resonance imaging (MRI) examinations showed the presence of CSF within the IAC around the preserved cranial nerves. Conclusions: This technique of IAC reconstruction after surgical resection of vestibular schwannomas may avoid scar and adhesion of muscle or fat tissue with preserved cranial nerves, allowing CSF enter inside the IAC. It may help to identify tumor remnants and/or recurrences in postoperative MRI examinations. Comparative studies are needed to evaluate if this technique improves postoperative hearing and facial nerve outcomes.

The Asterion-to-Transverse Process of the Atlas Line as a Surgical Landmark

2021 ◽  
Author(s):  
Jaafar Basma ◽  
Dom E. Mahoney ◽  
Christos Anagnostopoulos ◽  
L. Madison Michael ◽  
Jeffrey M. Sorenson ◽  
...  
Keyword(s):  
Skull Base ◽  
Cranial Nerves ◽  
Three Dimensional ◽  
Transverse Process ◽  
Jugular Foramen ◽  
Foramen Magnum ◽  
Sigmoid Sinus ◽  
Cervical Region ◽  
Surgical Approaches ◽  
Anatomical Location

Abstract Introduction Proposed landmarks to predict the anatomical location and trajectory of the sigmoid sinus have varying degrees of reliability. Even with neuronavigation technology, landmarks are crucial in planning and performing complex approaches to the posterolateral skull base. By combining two major dependable structures—the asterion (A) and transverse process of the atlas (TPC1)—we investigate the A-TPC1 line in relation to the sigmoid sinus and in partitioning surgical approaches to the region. Methods We dissected six cadaveric heads (12 sides) to expose the posterolateral skull base, including the mastoid and suboccipital bone, TPC1 and suboccipital triangle, distal jugular vein and internal carotid artery, and lower cranial nerves in the distal cervical region. We inspected the A-TPC1 line before and after drilling the mastoid and occipital bones and studied the relationship of the sigmoid sinus trajectory and major muscular elements related to the line. We retrospectively reviewed 31 head and neck computed tomography (CT) angiograms (62 total sides), excluding posterior fossa or cervical pathologies. Bone and vessels were reconstructed using three-dimensional segmentation software. We measured the distance between the A-TPC1 line and sigmoid sinus at different levels: posterior digastric point (DP), and maximal distances above and below the digastric notch. Results A-TPC1 length averaged 65 mm and was posterior to the sigmoid sinus in all cadaver specimens, coming closest at the level of the DP. Using the transverse-asterion line as a rostrocaudal division and skull base as a horizontal plane, we divided the major surgical approaches into four quadrants: distal cervical/extreme lateral and jugular foramen (anteroinferior), presigmoid/petrosal (anterosuperior), retrosigmoid/suboccipital (posterosuperior), and far lateral/foramen magnum regions (posteroinferior). Radiographically, the A-TPC1 line was also posterior to the sigmoid sinus in all sides and came closest to the sinus at the level of DP (mean, 7 mm posterior; range, 0–18.7 mm). The maximal distance above the DP had a mean of 10.1 mm (range, 3.6–19.5 mm) and below the DP 5.2 mm (range, 0–20.7 mm). Conclusion The A-TPC1 line is a helpful landmark reliably found posterior to the sigmoid sinus in cadaveric specimens and radiographic CT scans. It can corroborate the accuracy of neuronavigation, assist in minimizing the risk of sigmoid sinus injury, and is a useful tool in planning surgical approaches to the posterolateral skull base, both preoperatively and intraoperatively.

Pathology of Jugular Foramen Neurofibroma

1983 ◽  
Vol 92 (2) ◽  
pp. 128-133 ◽  
Author(s):  
Richard R. Gacek
Keyword(s):  
Conservative Treatment ◽  
Temporal Bone ◽  
Cranial Nerves ◽  
Internal Auditory Canal ◽  
Jugular Foramen ◽  
Glomus Jugulare Tumor ◽  
Tissue Diagnosis ◽  
Glomus Jugulare ◽  
Useful Life

Tumors of jugular foramen may closely resemble glomus jugulare tumors clinically and radiographically. A tissue diagnosis is necessary to make a differentiation of these tumors. This conclusion is supported by the findings in a temporal bone from a patient who was diagnosed clinically as having a glomus jugulare tumor 57 years before her death at the age of 84 years. Compression of the 7th and 8th cranial nerves in the internal auditory canal and the 10th and 11th cranial nerves at the jugular foramen represents the mechanism of neural signs produced by a neurofibroma arising in the jugulare foramen. This case further demonstrates that conservative treatment of benign extradural tumors may be compatible with a long and useful life.

scholarly journals Management of the Facial Nerve in Lateral Skull Base Surgery Analytic Retrospective study

2011 ◽  
Vol 4 ◽  
pp. CMENT.S6570 ◽  
Author(s):  
Mohamed A. El Shazly ◽  
Mahmoud A.M. Mokbel ◽  
Amr A. Elbadry ◽  
Hatem S. Badran
Keyword(s):  
Facial Nerve ◽  
Facial Paralysis ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Jugular Foramen ◽  
External Carotid ◽  
Vascular Tumors ◽  
Complete Cure ◽  
Glomus Jugulare ◽  
Lateral Skull Base

Background Surgical approaches to the jugular foramen are often complex and lengthy procedures associated with significant morbidity based on the anatomic and tumor characteristics. In addition to the risk of intra-operative hemorrhage from vascular tumors, lower cranial nerves deficits are frequently increased after intra-operative manipulation. Accordingly, modifications in the surgical techniques have been developed to minimize these risks. Preoperative embolization and intra-operative ligation of the external carotid artery have decreased the intraoperative blood loss. Accurate identification and exposure of the cranial nerves extracranially allows for their preservation during tumor resection. The modification of facial nerve mobilization provides widened infratemporal exposure with less postoperative facial weakness. The ideal approach should enable complete, one stage tumor resection with excellent infratemporal and posterior fossa exposure and would not aggravate or cause neurologic deficit. The aim of this study is to present our experience in handling jugular foramen lesions (mainly glomus jugulare) without the need for anterior facial nerve transposition. Methods In this series we present our experience in Kasr ElEini University hospital (Cairo–-Egypt) in handling 36 patients with jugular foramen lesions over a period of 20 years where the previously mentioned preoperative and operative rules were followed. The clinical status, operative technique and postoperative care and outcome are detailed and analyzed in relation to the outcome. Results Complete cure without complications was achieved in four cases of congenital cholesteatoma and four cases with class B glomus. In advanced cases of glomus jugulare (28 patients) (C and D stages) complete cure was achieved in 21 of them (75%). The operative complications were also related to this group of 28 patients, in the form of facial paralysis in 20 of them (55.6%) and symptomatic vagal paralysis in 18 of them (50%). Conclusions Total anterior rerouting of the facial nerve carries a high risk of facial paralysis. So it should be reserved for cases where the lesion extends beyond the vertical ICA. Otherwise, for less extensive lesions and less aggressive pathologies, less aggressive approaches could be adopted with less hazards.

scholarly journals Osteological studies of skull base neurovascular area in reference to infratemporal approach to skull basec

2021 ◽  
Vol 4 (3) ◽  
pp. 89-93
Author(s):  
Harsh Sharma
Keyword(s):  
Skull Base ◽  
Cranial Nerves ◽  
Relative Size ◽  
Jugular Foramen ◽  
Surgical Approaches ◽  
Carotid Canal ◽  
Stylomastoid Foramen ◽  
Lateral Skull Base ◽  
Infratemporal Approach ◽  
Relationship Of

Surgical approaches to the lateral skull base often lead to tearing of vessels and piecemeal removal of the tumour. This study is aimed to delineate exact relationship of the various foramina at the lateral skull base. The coronal dimensions of the jugular foramina are larger as compared to sagittal with right sided dominance also noticed in the case of carotid canal. The width of “Keel” separating the carotid and jugular foramina normally varies from 0.4 to1.4 centimetres and may not always suggest the erosion of the foramen of skull base scans, unless the erosion is associated with irregularity or demineralization the thickness of this keel really depends upon relative size of the vessels and location of foramina. Area between stylomastoid foramen, carotid canal and jugular foramen is roughly wedge shaped. The angle subtended by carotid and jugular at the stylomastoid foramen is about 36.84whereas the location of stylomastoid foramen and internal carotid axis pose an angle of 83:16. The angle subtended by stylomastoid and jugular at carotid on an average 59:31. The space between these structures is measured to be 0.642centimetres which can be verified on tomograms. By using these measurements, the precise location of the upper end of the vessels could be predicted, whereas the superior stump could be clamped with minimal exposure of the skull base and identification and location of the last four cranial nerves is found out. This could avoid injuries and subsequent morbidity while carrying out surgery in this region.

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