scholarly journals Clival Meningioma Removal through a Suboccipital Retrosigmoid Approach: Operative Video and Technical Nuances

2020 ◽  
Author(s):  
Carlos Candanedo ◽  
Samuel Moscovici ◽  
Sergey Spektor
Keyword(s):  
Evoked Potentials ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Retrosigmoid Approach ◽  
Lateral Skull Base ◽  
Adjacent Structures ◽  
Entry Points ◽  
Brainstem Response ◽  
Basilar Arteries ◽  
Lower Cranial Nerves

Abstract Background Clival meningiomas are challenging lesions that need to be managed according to the displacement of the adjacent structures. Lateral skull base approaches are needed to achieve their radical removal; however, they are associated with significant morbidity, especially when the tumor involves the basilar artery, its perforators, brainstem, and lower cranial nerves. Design This is a case of a 79-year-old female patient, diagnosed with a large lower clival meningioma after suffering from headaches. It was offered a conservative treatment but on serial MRI, an increase in the meningioma's size was observed, so it was decided to remove the meningioma using a left suboccipital retrosigmoid approach. Settings On a left three-quarter prone position, with facial nerve, auditory brainstem response, lower cranial nerves, and motor-evoked potentials and somatosensory-evoked potentials neurophysiologic monitoring, a right suboccipital retrosigmoid craniotomy with opening of the foramen magnum was performed, giving enough lateral visualization of the tumor. Broad base tumor pushing backward and aside the vertebral and basilar arteries, cranial nerves (7th–12th), and the brainstem was exposed and removed. Results Near total resection of the meningioma was achieved, leaving a microscopic residual in the entry points of the low cranial nerves without complications. There was no neurological deficit after the surgery. Postoperative MRI revealed no signs of residual tumor. Conclusion: In this case, the regular retrosigmoid approach, extended into the foramen magnum was enough for the removal of this pure clival meningioma.The link to the video can be found at: https://youtu.be/3d6Uj4gjmDU.

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
Keyword(s):  
Cranial Nerves ◽  
Craniocervical Junction ◽  
Foramen Magnum ◽  
Occipital Condyle ◽  
Formidable Challenge ◽  
Close Proximity ◽  
Vertebrobasilar Circulation ◽  
Far Lateral ◽  
Lower Cranial Nerves ◽  
Gain Access

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.

scholarly journals Endoscopic Resection of a Cerebellopontine Angle Meningioma via a Retrosigmoid Approach

2019 ◽  
Vol 80 (S 03) ◽  
pp. S310-S310
Author(s):  
Frederick Luke Hitti ◽  
John Y.K. Lee
Keyword(s):  
Cerebellopontine Angle ◽  
Brain Mri ◽  
Cranial Nerves ◽  
Vascular Supply ◽  
Retrosigmoid Approach ◽  
Tumor Capsule ◽  
Imaging Characteristics ◽  
Adjacent Structures ◽  
Patient Reported ◽  
The Right

A variety of lesions may arise within the cerebellopontine angle (CPA). Schwannomas and meningiomas are most commonly found in this location. Imaging characteristics of meningiomas include hyperdensity on head computed tomography (CT) and avid contrast enhancement on T1-weighted postcontrast magnetic resonance imaging (MRI). Here, we present the case of a 49-year-old woman with enlarging right CPA meningioma. The patient reported mild hearing loss on the right but her neurological exam was otherwise benign. Since the lesion was enlarging and symptomatic, the patient was offered resection of the mass for diagnosis and treatment via an endoscopic retrosigmoid approach. We provide a video that illustrates the steps taken to resect this mass endoscopically. After cerebrospinal fluid (CSF) was drained to achieve brain relaxation, the tumor was visualized. The tumor had a rich vascular supply and had the appearance of a typical meningioma. The bipolar was used to cauterize the tumor's vascular supply. The tumor capsule was then opened with the microscissors. The round knife, suction, and ultrasonic tissue debrider were used to debulk the tumor. After internal debulking of the tumor, the capsule was dissected off the cerebellum and mobilized. A combination of blunt and sharp dissection was done to free the tumor capsule from the adjacent structures. Inferiorly, the lower cranial nerves were visualized. Tissue pathology confirmed a diagnosis of grade I meningioma. A gross total resection was achieved and the patient remained neurologically stable, postoperatively. Furthermore, T1-weighted postcontrast brain MRI, 1 year after surgery, showed no residual.The link to the video can be found at: https://youtu.be/X9c_inLp-So.

Retrosigmoid approach for resection of petroclival meningioma

2014 ◽  
Vol 36 (v1supplement) ◽  
pp. 1 ◽  
Author(s):  
Anil Nanda ◽  
Sudheer Ambekar
Keyword(s):  
Cranial Nerves ◽  
Retrosigmoid Approach ◽  
Bone Flap ◽  
Petroclival Meningioma ◽  
Link Type ◽  
Key Steps ◽  
Lower Cranial Nerves ◽  
Neurovascular Structures

This video describes the classic retrosigmoid approach for the resection of petroclival lesions. In this procedure, a careful dissection of the tumor within the arachnoid plane from the neurovascular structures is described. The key steps in the procedure are outlined, and include positioning, tumor devascularization, decompression, dissection from lower cranial nerves, IV, V cranial nerves and the VII-VIII complex and from the brainstem and closure of the dura, bone flap and the incision.The video can be found here: http://youtu.be/DmutL7dBOxI.

scholarly journals Technical strategies to approach aneurysms of the vertebral and posterior inferior cerebellar arteries

2005 ◽  
Vol 19 (2) ◽  
pp. 1-5 ◽  
Author(s):  
Niklaus Krayenbühl ◽  
Carlos A. Guerrero ◽  
Ali F. Krisht
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Anatomical Location ◽  
Microsurgical Anatomy ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Pica Aneurysms ◽  
Lower Cranial Nerves

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.

Surgical approaches to posterior fossa tumours

2019 ◽  
pp. 375-382
Author(s):  
Jacques J. Morcos ◽  
Osaama Khan ◽  
Ashish H. Shah
Keyword(s):  
Posterior Fossa ◽  
Fourth Ventricle ◽  
Cranial Nerves ◽  
Surgical Techniques ◽  
Foramen Magnum ◽  
Surgical Approaches ◽  
Tumour Resection ◽  
Surgical Morbidity ◽  
Preoperative Workup ◽  
Lower Cranial Nerves

Lesions of the fourth ventricle and foramen magnum can be difficult to manage surgically due to their proximity to critical brainstem structures. Understanding the anatomy of the fourth ventricle, lower cranial nerves, and basilar cisterns remains paramount for deciding surgical approaches to this location. Detailed preoperative workup and planning are necessary to minimize surgical morbidity and maximize tumour resection. This chapter provides an overview of the relevant anatomy and surgical techniques for lesions in the posterior fossa, specifically the fourth ventricle the foramen magnum. We will split this chapter into two main sections: microsurgical approaches to the fourth ventricle and skull base approaches to the foramen magnum.

Continuous Laryngoscopic Vocal Cord Monitoring for Vascular Malformation Surgery in the Medulla Oblongata: Technical Note

Neurosurgery ◽  
2004 ◽  
Vol 54 (1) ◽  
pp. 232-235 ◽  
Author(s):  
Yoshinori Tamano ◽  
Hiroshi Ujiie ◽  
Takakazu Kawamata ◽  
Tomokatsu Hori
Keyword(s):  
Postoperative Complications ◽  
Evoked Potentials ◽  
Vocal Cord ◽  
Medulla Oblongata ◽  
Fourth Ventricle ◽  
Cranial Nerves ◽  
Posterior Pharyngeal Wall ◽  
Spontaneous Respiration ◽  
Pharyngeal Wall ◽  
Lower Cranial Nerves

Abstract OBJECTIVE Resection of lesions located in the medulla oblongata may result in significant morbidity. The most lethal complications are swallowing disturbances, which can lead to aspiration pneumonia. To prevent this problem, the lower cranial nerves can be mapped with recording needles placed in the posterior pharyngeal wall and the tongue. However, mapping alone is not sufficient to preserve the lower cranial nerves and swallowing functions. To overcome this problem, we attempted to devise a method to intraoperatively monitor vocal cord movements with a laryngoscope. We used this method, in addition to other types of brainstem mapping, in three cases. METHODS Recording needles were inserted into the posterior pharyngeal wall and the tongue, to record the responses of Cranial Nerves IX and XII. A laryngoscope was inserted orally, for direct observation of vocal cord movements, and was maintained until the end of the operation. The floor of the fourth ventricle was stimulated with a monopolar stimulator. Somatosensory evoked potentials, auditory evoked potentials, and motor evoked potentials were simultaneously monitored. RESULTS We were able to confirm synchronized vocal cord adduction with stimulation of the expected vagal trigonum location and to monitor rhythmic vocal cord movements during spontaneous respiration. In all three cases, we removed the lesions without postoperative complications. CONCLUSION In addition to intraoperative vocal cord monitoring with a laryngoscope, we could safely determine the optimal location for the first incision in the floor of the fourth ventricle. Potentially lethal postoperative complications can be avoided with brainstem mapping and vocal cord monitoring.

scholarly journals Endoscopic Endonasal Approach to Foramen Magnum Meningioma—Technical Note and Case Example

2018 ◽  
Vol 37 (04) ◽  
pp. 362-366
Author(s):  
Flavio Romero ◽  
Rodolfo Vieira ◽  
Bruno Ancheschi
Keyword(s):  
Cranial Nerves ◽  
Craniocervical Junction ◽  
Foramen Magnum ◽  
Technical Note ◽  
Open Approach ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Midline Approach ◽  
Lower Cranial Nerves

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.

scholarly journals Endoscopic-Assisted Resection of Anterior Foramen Magnum Meningiomas through a Midline Suboccipital Subtonsillar Approach

2021 ◽  
Author(s):  
Florian Roser ◽  
Luigi Rigante
Keyword(s):  
Anterior Part ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Anterior Portion ◽  
Suboccipital Craniotomy ◽  
Dural Attachment ◽  
Surgical Corridor ◽  
Lower Cranial Nerves ◽  
Brain Retraction

Abstract Objective This study was aimed to demonstrate the resection of anterior foramen magnum meningiomas through an endoscopic-assisted posterior midline suboccipital subtonsillar approach. Design This study was designed with illustration of the surgical steps and safety of this approach. Setting Evidence of cerebrospinal fluid (CSF) cleft between the tumor and brainstem on MRI was studied (Fig. 1A and B). Preoperative tracheotomy was considered in cases of preoperative dysphagia to prevent any further neurological deterioration due to the bilateral access through the lower cranial nerves corridors. Semisitting position with extensive electrophysiological neuromonitoring and transesophageal echocardiogram was adopted. A standard midline incision with bilateral suboccipital craniotomy and C1-laminotomy was performed (Fig. 2A). After partial resection and elevation of the tonsils, tumor was debulked unilaterally around the lower cranial nerves and the vertebral artery, devascularized from the clival dura and then dissected from the brainstem (Fig. 2B, C). Endoscopic-assisted removal of its anterior portion followed. The same procedure was repeated from the opposite site for the contralateral portion, before approaching the purely anterior part with endoscope assistance (Fig. 2D). Participants Four consecutive patients were included in the study. Main Outcome Measures Grade of tumor resection and outcome (mRS) were primary measurement of this study. Results Clinical outcome and grade of resection are comparable to other series of patient treated with other foramen magnum approaches (Fig. 1C and D). Conclusion Anterior foramen magnum meningiomas can be safely removed through this relatively faster midline suboccipital approach with bilateral exposure of lower cranial nerves (CNs) and vertebral arteries and lower approach-related morbidity (no condyle drilling). The surgical corridor is created by the tumor during debulking reducing need for brain retraction and the removal of the anterior dural attachment coagulated under the microscope is verified and completed endoscopically with pituitary curettes (Simpson's grade II) (Fig. 1C and D).The link to the video can be found at: https://youtu.be/9eACAJVwQBs.

An endoscopic assisted retrosigmoid approach to the cerebello-pontine angle for resection of an epidermoid cyst

2014 ◽  
Vol 36 (v1supplement) ◽  
pp. 1 ◽  
Author(s):  
Mina G. Safain ◽  
Walter C. Dent ◽  
Carl B. Heilman
Keyword(s):  
Epidermoid Cyst ◽  
Cranial Nerves ◽  
Complete Removal ◽  
Retrosigmoid Approach ◽  
Intracranial Tumors ◽  
Lower Lip ◽  
Epidermoid Cysts ◽  
Link Type ◽  
Lower Cranial Nerves ◽  
Neurovascular Structures

Epidermoid cysts are rare lesions accounting for 1% of intracranial tumors with approximately 50% located within the cerebello-pontine angle (CPA). Resection is complicated by their close anatomical relation to critical neurovascular structures and their tendency to be densely adherent making complete removal a significant neurosurgical challenge. We present a 35-year-old woman with left sided tongue numbness and lower lip paresthesias with a CPA epidermoid. An endoscopic assisted retrosigmoid approach was utilized for resection. A 30-degree endoscope was used to assist in removal of unseen tumor in Meckel's cave, medial to the lower cranial nerves, and along the ventral pons.The video can be found here: http://youtu.be/bv0lMPbX7BY.

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