scholarly journals Far Lateral Craniotomy for Resection of Foramen Magnum Meningioma

2019 ◽  
Vol 80 (S 04) ◽  
pp. S355-S357
Author(s):  
Robert T. Wicks ◽  
Xiaochun Zhao ◽  
Celene B. Mulholland ◽  
Peter Nakaji

Abstract Objective Foramen magnum meningiomas present a formidable challenge to resection due to frequent involvement of the lower cranial nerves and vertebrobasilar circulation. The video shows the use of a far lateral craniotomy to resect a foramen magnum meningioma. Design, Setting, and Participant A 49-year-old woman presented with neck pain and was found to have a large foramen magnum meningioma (Fig. 1A, B). Drilling of the posterior occipital condyle was required to gain access to the lateral aspect of the brain stem. The amount of occipital condyle resection varies by patient and pathology. Outcome/Result Maximal total resection of the tumor was achieved (Fig. 1B, C), and the patient was discharged on postoperative day 4 with no neurologic deficits. The technique for tumor microdissection (Fig. 2) is shown in the video. Conclusion Given the close proximity of foramen magnum meningiomas to vital structures at the craniocervical junction, surgical resection with careful microdissection and preservation of the overlying dura to prevent postoperative pseudomeningocele is necessary to successfully manage this pathology in those patients who are surgical candidates.The link to the video can be found at: https://youtu.be/Mds9N1x2zE0.

2019 ◽  
Vol 80 (S 04) ◽  
pp. S363-S364
Author(s):  
Ciro Vasquez ◽  
Alexander Yang ◽  
A. Samy Youssef

We present a case of a foramen magnum meningioma in a 42-year-old female who presented with headaches for 2 years, associated with decreased sensation and overall feeling of “heaviness” of the right arm. The tumor posed significant mass effect on the brainstem, and given the location of the tumor in the anterolateral region of the foramen magnum, a right far lateral approach was chosen. The approach incorporates the interfascial dissection technique to safely expose and preserve the vertebral artery in the suboccipital triangle. After drilling the posteromedial portion of the occipital condyle and opening the dura, the tumor can be entirely exposed with minimal retraction on the cerebellum. The working space offered by the far lateral approach allows careful dissection at the lateral craniocervical junction, and preservation of the V4 segment of the vertebral artery and the lower cranial nerves. Simpson's grade-2 resection was achieved with coagulation of the dural base around the vertebral artery. The postoperative course was unremarkable for any neurological deficits. At the 2-year follow-up, imaging identified no recurrence of tumor and the patient remains asymptomatic.The link to the video can be found at: https://youtu.be/IMN1O7vO5B0.


2005 ◽  
Vol 19 (2) ◽  
pp. 1-5 ◽  
Author(s):  
Niklaus Krayenbühl ◽  
Carlos A. Guerrero ◽  
Ali F. Krisht

Object Aneurysms of the vertebral artery (VA) and proximal posterior inferior cerebellar artery (PICA) are rare and challenging lesions, as they are located in front of the brainstem and surrounded by the lower cranial nerves. Many different approaches have been described for their treatment, and have yielded different results. With the use of different examples of lesions, the authors describe their surgical strategy in the management of VA and PICA aneurysms. Methods The far-lateral approach was used, and the potential of its different extensions according to the specific anatomical location and configuration of different types of aneurysms is emphasized. Conclusions With the present knowledge of the microsurgical anatomy in the region of the foramen magnum, the far-lateral approach can be tailored to the specific anatomical and morphological configuration of an aneurysm in this region with good surgical results.


2018 ◽  
Vol 37 (04) ◽  
pp. 362-366
Author(s):  
Flavio Romero ◽  
Rodolfo Vieira ◽  
Bruno Ancheschi

AbstractForamen magnum (FM) tumors represent one of the most complex cases for the neurosurgeon, due to their location in a very anatomically complex region surrounded by the brainstem and the lower cranial nerves, by bony elements of the craniocervical junction, and by the vertebrobasilar vessels. Currently, the open approach of choice is a lateral extension of the posterior midline approach including far lateral, and extreme lateral routes. However, the transoraltranspharyngeal approach remains the treatment of choice in cases of diseases affecting the craniocervical junction. For very selective cases, the endoscopic endonasal route to this region is another option. We present a case of a ventral FM meningioma treated exclusively with the endoscopic endonasal approach.


2021 ◽  
Author(s):  
Kunal V Vakharia ◽  
Ryan M Naylor ◽  
Jamie J Van Gompel

Abstract Neurenteric cysts are rare congenital lesions that may compress the ventral brainstem.1-9 In this operative video, we illustrate the surgical treatment of an intradural extra-axial neurenteric cyst extending from the lower pons to the craniocervical junction. The patient, an asymptomatic 52-yr-old female, underwent surveillance imaging of the premedullary lesion for 14 yr without progression. However, after developing progressive strain-induced headaches, imaging revealed a significant enlargement of the lesion with brainstem compression and partial obstruction of the foramen magnum. Therefore, surgical resection was pursued. The patient consented to the procedure. The patient underwent a lateral suboccipital craniotomy and C1 laminectomy through a far lateral approach. The lesion was immediately visualized upon opening the dura. After identifying the cranial nerves, we resected the tumor while taking care to preserve the neurovascular elements of the cerebellopontine angle and foramen magnum. During the resection, we unexpectedly encountered a firm nodule that was adherent to the right posterior inferior cerebellar artery. This was meticulously dissected and removed en bloc using intraoperative indocyanine green (ICG) angiography. The cavity was inspected with 0-degree and 30-degree endoscopes to ensure complete resection of the lesion. Gross total resection was confirmed on postoperative magnetic resonance imaging. The patient was neurologically intact with no cranial nerve abnormalities and discharged home on postoperative day 3. This case demonstrates that the far lateral-supracondylar approach affords safe access to the ventral pontomedullary and craniocervical junctions and that intraoperative adjuncts, including ICG angiography and endoscopic visualization, can facilitate complete lesion resection with excellent clinical outcomes.


2010 ◽  
Vol 66 (suppl_2) ◽  
pp. ons211-ons220 ◽  
Author(s):  
Victor A. Morera ◽  
Juan C. Fernandez-Miranda ◽  
Daniel M. Prevedello ◽  
Ricky Madhok ◽  
Juan Barges-Coll ◽  
...  

Abstract OBJECTIVE The endoscopic endonasal transclival approach is a valid alternative for treatment of lesions in the clivus. The major limitation of this approach is a significant lateral extension of the tumor. We aim to identify a safe corridor through the occipital condyle to provide more lateral exposure of the foramen magnum. METHODS Sixteen parameters were measured in 25 adult skulls to analyze the exact extension of a safe corridor through the condyle. Endonasal endoscopic anatomic dissections were carried out in nine colored latex–injected heads. RESULTS Drilling at the lateral inferior clival area exposed two compartments divided by the hypoglossal canal: the jugular tubercle (superior) and the condylar (inferior). Completion of a unilateral ventromedial condyle resection opens a 3.5 mm (transverse length) * 10 mm (vertical length) lateral surgical corridor, facilitating direct access to the vertebral artery at its dural entry point into the posterior fossa. The supracondylar groove is a reliable landmark for locating the hypoglossal canal in relation to the condyle. The hypoglossal canal is used as the posterior limit of the condyle removal to preserve more than half of the condylar mass. The transjugular tubercle approach is accomplished by drilling above the hypoglossal canal, and increases the vertical length of the lateral surgical corridor by 8 mm, allowing for visualization of the distal cisternal segment of the lower cranial nerves. CONCLUSION The transcondylar and transjugular tubercle “far medial” expansions of the endoscopic endonasal approach to the inferior third of the clivus provide a unique surgical corridor to the ventrolateral surface of the ponto- and cervicomedullary junctions.


Author(s):  
Vinayak Narayan ◽  
Fareed Jumah ◽  
Anil Nanda

Abstract Objectives Safe maximal resection is the basic principle of cranial base surgery and the grade of resection is an important factor influencing the prognostic outcome. This operative video highlights the surgical principles and technical nuances in the microsurgical resection of foramen magnum meningioma (FMM). Case Description The surgery was performed in a 45-year-old lady who presented with hoarseness of voice and spastic quadriparesis (grade 4/5). On imaging, FMM with mass effect on brainstem and spinal cord was identified. The tumor was gross totally resected through modified far lateral approach with minimal occipital condyle drilling. This video demonstrates the surgical techniques of tumor resection including early devascularization, operating in the arachnoid plane to dissect the neurovascular structures, piecemeal decompression, sharp dissection to separate tumor from lower cranial nerves (LCN), identifying the brainstem veins, and resecting the lesion from tumor–brainstem interface. Postoperatively, she had significant neurological improvement and the magnetic resonance imaging revealed excellent radiological outcome (Figs. 1 and 2). Conclusion The surgery of FMM is challenging due to the deep surgical corridor, critical location, close proximity with various neurovascular structures, firm consistency, and high vascularity of the tumor. The modified far lateral approach by preserving the occipital condyle may prevent the postoperative incidence of craniovertebral junction instability. The key operative principles to achieve the best surgical outcome include careful dissection along the arachnoid plane, gentle handling of cranial nerves, veins, and perforator vessels, avoidance of traction on brainstem and spinal cord, intraoperative neurophysiological monitoring, proper hemostasis, and meticulous dural closure.The link to the video can be found at: https://youtu.be/1qvAeUmNIUw.


2002 ◽  
Vol 96 (2) ◽  
pp. 302-309 ◽  
Author(s):  
Anil Nanda ◽  
David A. Vincent ◽  
Prasad S. S. V. Vannemreddy ◽  
Mustafa K. Baskaya ◽  
Amitabha Chanda

Object. The goal of this study was to determine whether drilling out the occipital condyle facilitates surgery via the far-lateral approach by comparing data from 10 clinical cases with that from studies of eight cadaver heads. Methods. During the last 6 years at Louisiana State University Health Sciences Center—Shreveport, 10 patients underwent surgery via the far-lateral approach to the foramen magnum. Six of these patients harbored anterior foramen magnum meningiomas, one patient a dermoid cyst, two patients vertebral artery (VA) aneurysms, and an additional patient suffered from rheumatoid disease of the craniocervical junction. The surgical approach consisted of retromastoid craniectomy and C-1 laminectomy. The seven tumors and the pannus of rheumatoid disease were completely excised, and the two aneurysms were clipped without drilling the occipital condyle. In one patient a chronic subdural hematoma was found 3 months after surgery, but no patient displayed any complication associated with surgery. It is significant that in no patient was a cerebrospinal fluid leak present. All patients experienced improved neurological function postoperatively. To compare surgical visibility, eight cadaveric specimens (16 sides) were studied, including delineation of the VA and its segments around the craniocervical junction. Increase in visibility as a function of fractional removal of the occipital condyle was quantified by measuring the degrees of visibility gained by removing one third and one half of the occipital condyle. Removal of one third of the occipital condyle produced a mean increase of 15.9° visibility, and removal of one half produced a mean increase of 19.9°. Conclusions. On the basis of their findings the authors conclude that removal of the occipital condyle is not necessary for the safe and complete resection of anterior intradural foramen magnum tumors.


2019 ◽  
Vol 80 (S 04) ◽  
pp. S365-S367
Author(s):  
Stefan Lieber ◽  
Maximiliano Nunez ◽  
Rocio Evangelista-Zamora ◽  
Marcos Tatagiba

AbstractWe present a case of a medium-sized foramen magnum meningioma that was resected through a midline suboccipital subtonsillar approach with C1 laminectomy in prone (Concorde) position. The patient is a 77-year-old woman with a 6-month history of intermittent vertigo, moderate gait instability, and slight decline of memory.On magnetic resonance imaging (MRI) an extra-axial intradural lesion was discovered that originated from the right epicondylar region just inferior to the jugular tubercle and occupied the anterolateral aspect of the foramen magnum. There was moderate transposition and compression of the medulla at the level of the cerebellar tonsils.On physical examination the patient was ambulatory independently without motor weakness but exhibited some gait instability. The function of the lower cranial nerves was preserved.A gross-total resection was achieved, histopathology confirmed a WHO grade-I meningothelial meningioma with a low-proliferation index. The patient was discharged home 5 days after surgery, her gait instability improved significantly immediately after surgery and had resolved completely after 2 weeks of inpatient rehabilitation. There was no other neurological deficit. At 3-month follow-up MRI, there was no indication of meningioma residual or recurrence.In summary, the midline suboccipital subtonsillar approach is a powerful tool with limited morbidity in the armamentarium for the microsurgical management of a variety of pathologies residing in the posterior cranial fossa and the craniocervical junction. Oftentimes the space created by the pathology opens up corridors that can be exploited for microsurgical access to avoid more extensive surgical approaches.The link to the video can be found at: https://youtu.be/0uUxs13ze7w.


2006 ◽  
Vol 177 (2) ◽  
pp. 97-104 ◽  
Author(s):  
Marie Pincemaille-Quillevere ◽  
Eric Buffetaut ◽  
Frédéric Quillevere

Abstract Since the 19th century, the Campanian and Maastrichtian continental deposits of southern France have yielded numerous dinosaur remains [Le Loeuff, 1991; 1998; Buffetaut et al., 1997; Laurent et al., 1991; Allain and Suberbiola, 2003]. The ornithopod remains that have not been referred to the hadrosaurids have been systematically attributed to Rhabdodon [Buffetaut and Le Loeuff, 1991; Buffetaut et al., 1996; Garcia et al., 1999; Pincemaille-Quillévéré, 2002]. This genus, initially named by Matheron [1869] after its discovery in the lower Maastrichtian of La Nerthe (Bouches-du-Rhône), belongs to the Euornithopoda [sensu Sereno, 1999]. Rhabdodon represents the most common element of the dinosaur assemblages from the late Cretaceous of southern France [e.g. Allain and Suberbiola, 2003]. Nevertheless, since the localities have only provided some fragmentary material [Pincemaille-Quillévéré, 2002], the global morphology of this dinosaur and its phylogenetic placement within the euornithopods are still debated. The cranial morphology of Rhabdodon is particularly poorly understood due to the rarity of cranial remains preserved in the localities of southern France [Matheron, 1869; Garcia et al., 1999; Buffetaut et al., 1999; Pincemaille-Quillévéré, 2002]. Buffetaut et al. [1999] first mentioned the discovery of a braincase (M4) referred to Rhabdodon, at Massecaps, a locality close to the village of Cruzy (Hérault, France). More recently, a new braincase (MN25) has been discovered at Montplô Nord, another locality close to Cruzy (specimens M4 and MN25 are conserved in the Museum of Cruzy). Both these localities have revealed a diverse and abundant vertebrate fauna suggesting a late Campanian to early Maastrichtian age [Buffetaut et al., 1999]. These braincases are described here in an attempt to detect potential autapomorphic characters in Rhabdodon, and compared to a more complete braincase of Tenontosaurus, an euornithopod from the Lower Cretaceous of North America, considered as the sister group of Rhabdodon [Weishampel et al., 1998; 2003; Garcia et al., 1999; Pincemaille-Quillévéré, 2002], in order to determine the potential differences and synapomorphies between the occiputs of the two genera. Finally, the braincases from Cruzy are compared to those of the other euornithopods described in the literature. Specimen M4 (figs. 1–4) is incomplete but exceptionally well preserved. This braincase belongs to a juvenile individual, as shown by the numerous visible suture lines between the different cranial elements. Specimen MN25 (fig. 5) is badly deformed and attributable to an adult individual. Until now, all the ornithopods from the Upper Cretaceous of southern France have been referred either to hadrosaurs or to Rhabdodon. The Hadrosauridae show a low nuchal crest and their exoccipitals meet and form a bar on the dorsal border of the foramen magnum, excluding the supraoccipital from this border. Specimens M4 and MN25 do not present any nuchal crest and the supraoccipital participates in the dorsal border of the foramen magnum. Both braincases M4 and MN25 are therefore attributable to Rhabdodon. Specimens M4 and MN25 have been compared to the occiput of a juvenile Tenontosaurus tilletti (fig. 6 : MCZ 4205, conserved in the Museum of Comparative Zoology, Harvard University). This reveals that Tenontosaurus and Rhabdodon share numerous characters : (1) the exoccipitals form the lateral borders of the foramen magnum, its ventral border being occupied by the basioccipital; (2) the occipital condyle is partly constituted by the exoccipitals, and in the same proportions; (3) the supraoccipital is rostrally oriented; (4) the suture line located between the prootic and the laterosphenoid shows the same outline; (5) the cresta prootica starts within the paroccipital process and extends onto the opisthotic; (6) the cresta prootica is transversal and non-horizontal; (7) the distribution of the cranial nerves is homologuous along the lateral surface of the braincase. Nevertheless, the braincase of Tenontosaurus differs from that of Rhabdodon in several significant respects : (1) the exoccipitals are dorsally connected, excluding the supraoccipital from the dorsal border of the foramen magnum; (2) two small dorsal humps are present at the level of the suture of the exoccipitals; (3) the supraoccipital is excluded from the dorsal border of the foramen magnum, which gives it a triangular shape; (4) the paroccipital processes are short, laterally flattened, and wing-shaped, and are more mediodorsally oriented than in Rhabdodon; (5) the cresta prootica follows a concave line and ends up on the prootic, at the level of the opening of the trigeminal nerve; (6) the external curve of the laterosphenoids is stronger; (7) the suture between the basioccipital and the opisthotic is very clear. The first of these unshared characters suggests that Rhabdodon belongs to Norman’s [1984] ‘hypsilophodontoid’ clade and Tenontosaurus to the more evolved ‘iguanodontoid’ clade. The fusion of the exoccipitals on the dorsal border of the foramen magnum, together with other cranial adaptations, may have reduced the stress caused by a more elaborate mastication. Rhabdodon appears to have had a more primitive type of mastication. The strip formed by the reunion of the exoccipitals is less expanded dorsoventrally in Tenontosaurus tilletti than in the ‘iguanodontoid’ and ‘hadrosauroid’ clades. Tenontosaurus may therefore represent an intermediate group between the ‘hypsilophodontoid’ and ‘iguanodontoid’ clades.


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