Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Middle Fossa Approaches and Anterior Petrosectomy, Surgical Principles, and Illustrative Cases

2021 ◽  
Author(s):  
Laura Salgado-Lopez ◽  
Avital Perry ◽  
Christopher S. Graffeo ◽  
Lucas P. Carlstrom ◽  
Luciano C.P.C. Leonel ◽  
...  
Keyword(s):  
Skull Base ◽  
Posterior Fossa ◽  
Internal Auditory Canal ◽  
Middle Meningeal Artery ◽  
Surgical Anatomy ◽  
Direct Access ◽  
Middle Fossa ◽  
Muscle Flaps ◽  
Tegmen Tympani ◽  
Anterior Petrosectomy

Abstract Introduction The middle fossa (MF) approaches encompass a group of versatile surgical accesses to pathologies in the MF, internal auditory canal (IAC), and superomedial aspect of the posterior fossa. Although many descriptions of the MF approaches have been published, a practical surgical guide that allows an easy understanding for Skull Base trainees is needed. Methods Three formalin-fixed, colored-injected specimens were dissected under microscopic magnification (six sides). A MF craniotomy followed by IAC drilling was performed on three sides, and anterior petrosectomy (AP) was performed in the remaining three sides. The anatomical dissection was documented in stepwise three-dimensional photographic images. Following dissection, representative case applications were reviewed. Results The MF approach provides direct access to the MF structures and IAC. The AP provides excellent access to the superomedial aspect of the posterior fossa. Key common steps include: positioning and skin incision; scalp and muscle flaps; burr holes; craniotomy flap elevation; dural dissection along the petrous ridge; division of the middle meningeal artery; and exposure of the greater superficial petrosal nerve, tegmen tympani, and V3. Then, to approach the IAC: superior IAC drilling, and longitudinal dura opening. The area drilled in the AP approach forms a pentagon limited by the petrous internal carotid artery, cochlea, IAC, petrous ridge, and lateral border of V3. Conclusion The MF approaches are challenging. Operatively oriented skull base dissections provide a crucial foundation for learning these techniques. We describe comprehensive step-by-step approaches intended to develop familiarity in the cadaver laboratory and facilitate understanding of their potential for skull base disorders. Basic surgical principles are described to help in the operating room as well as illustrative cases.

scholarly journals Transzygomatic extended middle fossa approach for upper petroclival skull base lesions

2008 ◽  
Vol 25 (6) ◽  
pp. E5 ◽  
Author(s):  
Jin-cheng Zhao ◽  
James K. Liu
Keyword(s):  
Skull Base ◽  
Internal Auditory Canal ◽  
Direct Access ◽  
Petrous Apex ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
Trigeminal Root ◽  
Skull Base Lesions ◽  
Anterior Petrosectomy ◽  
Surgical Corridor

Central skull base lesions in the upper retroclival and petroclival regions can be challenging to access because of their location anterior to the brainstem. Several transpetrosal approaches have been developed to access the petroclival junction, including anterior petrosal (anterior petrosectomy), posterior petrosal (retrolabyrinthine, translabyrinthine, transcochlear), and combined petrosal approaches. The anterior petrosal approach is best suited for upper petroclival lesions located anterior and superior to the internal auditory canal and superior to the inferior petrosal sinus. This approach provides direct access to the anteromedial cerebellopontine angle, petrous apex, Meckel cave, and ventrolateral brainstem between the trigeminal root and the facial nerve. The authors describe their modification of an anterior petrosal approach, the so-called transzygomatic extended middle fossa approach, which incorporates a zygomatic osteotomy, anterior mobilization of the V3, and extensive middle fossa drilling. This exposure provides a wider surgical corridor for direct view of the clivus and ventral brainstem.

A Rare Case of Temporal Bone Pneumocephalus Tracking through the Internal Auditory Canal

ORL ◽  
2020 ◽  
pp. 1-4
Author(s):  
WayAnne Watson ◽  
Erin Mulry ◽  
Adam Kaufman ◽  
Steven J. Eliades
Keyword(s):  
Skull Base ◽  
Temporal Bone ◽  
Rare Case ◽  
Internal Auditory Canal ◽  
Anterior Skull Base ◽  
Shunt Revision ◽  
Middle Fossa ◽  
Chronic Hydrocephalus ◽  
Skull Base Reconstruction ◽  
The Right

A 39-year-old male with chronic hydrocephalus requiring biventricular shunts presented with progressive pneumocephalus over several years. He showed no improvement following ventriculoperitoneal (VP) shunt revision and anterior skull base repair for a sphenoid dehiscence. Imaging continued to show worsening pneumocephalus with air tracking along the right facial nerve from the geniculate ganglion to the internal auditory canal (IAC). The patient then underwent tympanomastoidectomy and skull base reconstruction. Based on a search of published literature, this appears to be the first reported case of temporal bone pneumocephalus coursing through the IAC, unlike most cases associated with tegmen defects and middle fossa pneumocephalus.

Anterior Petrosal [Kawase] Approach to Meckel's Cave Meningioma: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Nickalus R Khan ◽  
Jason I Liounakos ◽  
Jacques J Morcos
Keyword(s):  
Surgical Anatomy ◽  
Disease Entity ◽  
Middle Fossa ◽  
Meckel’S Cave ◽  
Case Presentation ◽  
Middle Fossa Approach ◽  
Meckel's Cave ◽  
Inflammatory Processes ◽  
Anterior Petrosectomy ◽  
Sixth Nerve

Abstract Meningiomas arising from Dorello's canal1-3 are a rare disease entity often resulting in an unclear diagnosis even at the time of surgery.4,5 We present a case of a 63-yr-old man who presented with a sixth nerve palsy. He was found to have a lesion in the region of Meckel's cave on neuroimaging studies. Additionally, there were cutaneous and joint complaints that gave rise to a clinical possibility of sarcoidosis. The differential diagnosis also included meningioma or other inflammatory processes. The patient underwent a right-sided middle fossa approach and partial anterior petrosectomy (Kawase approach). Meckel's cave was opened, the tumor resected, and the petrosphenoid ligament (Gruber's) was identified. It was a meningioma. The case presentation, surgical anatomy, technique, and postoperative course and outcome are reviewed.  The patient gave verbal consent for participating in the procedure and surgical video.

scholarly journals Morphometric Study of the Posterior Fossa: Identification of Practical Parameters for Tailored Selection of Surgical Routes to the Petroclival Region

2020 ◽  
Author(s):  
Zaid Aljuboori ◽  
Ahmad Alhourani ◽  
Mohammed Nuru ◽  
Candice Nguyen ◽  
Heegook Yeo ◽  
...  
Keyword(s):  
Skull Base ◽  
Surface Area ◽  
Posterior Fossa ◽  
Interobserver Reliability ◽  
Internal Auditory Canal ◽  
Petrous Apex ◽  
Morphometric Study ◽  
Petroclival Region ◽  
The Mean ◽  
Surgical Corridor

Abstract Introduction The petroclival region is an integral part of the skull base. It can harbor different pathologies and provides access to the petroclival junction and cerebellopontine angle. We present the results of the morphometric analysis of the posterior fossa and a prediction model to enable skull base surgeons to choose an optimal surgical corridor considering patient's bony anatomy. Methods Ninety patients (14 to assess interobserver reliability) with temporal bone computed tomography were selected. Exclusion criteria included patients <18 years of age, radiographic evidence of trauma, infection, or previous surgery. The images were analyzed using OsiriX MD (Bernex, Switzerland). We recorded clival length, vertical angle, and surface area, and petroclival angle, petrous apex, and translabyrinthine corridors volume. Results The average age was 49.5 years (55%) for males. The mean clival length and surface areas were 44.2 mm (standard deviation [SD] ± 4.1) and 8.1 cm2 (SD ± 1.3). The mean petrous apex and translabyrinthine corridors volumes were 2.2 cm3 (SD ± 0.6) and 10.1 cm3 (SD ± 3.7). The mean petroclival angle at the internal auditory canal (IAC) was 154.9 degrees (SD ± 9). The clival length correlated positively with clival surface area (rho = 0.6, p <0.05), petrous apex volume (rho = 0.3, p < 0.05), and translabyrinthine volume (rho = 0.3, p < 0.05). Conclusion The petroclival region is complex and with high variability of surgical significance. The use of preoperative measurements of the clival length and petroclival angle as part of surgical planning that could help the surgeon to choose an optimal surgical corridor by overcoming the anatomical variability elements.

Cerebrospinal Fluid Leaks of the Posterior Fossa: Patient Characteristics and Imaging Features

2019 ◽  
Author(s):  
Kristen L. Yancey ◽  
Nauman F. Manzoor ◽  
Robert J. Yawn ◽  
Matthew O'Malley ◽  
Alejandro Rivas ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Posterior Fossa ◽  
Case Series ◽  
Preoperative Imaging ◽  
Imaging Features ◽  
Lateral Skull Base ◽  
Tegmen Tympani ◽  
Significant Difference ◽  
Cerebrospinal Fluid Leaks

Abstract Objectives The main purpose of this article is to investigate the prevalence and features of posterior fossa defects (PFD) in spontaneous cerebrospinal fluid leaks (sCSFL). Design Retrospective case series. Setting Tertiary skull base center. Participants Consecutive adults undergoing lateral skull base repair of sCSFL between 2003 and 2018. Main Outcome Measures The following data were collected: demographics, comorbidities, radiology and intraoperative findings, and surgical outcomes including complications and need for revision surgery or shunt placement. Patients with incomplete data or leaks following skull base surgery, trauma, or chronic ear disease were excluded. Results Seventy-one patients (74% female, mean age 56.39 ± 11.50 years) underwent repair of spontaneous lateral skull base leaks. Eight ears (7 patients, 11.1%) had leaks involving the posterior fossa plate in addition to defects of the tegmen mastoideum (50%), tegmen tympani (25%), or both (25%). Patients with PFDs more often had bilateral tegmen thinning on imaging (75%, odds ratio [OR]: 10.71, 95% confidence interval [CI]: 2.20–54.35, p = 0.005) and symptomatic bilateral leaks (OR: 9.67, 95% CI: 2.22–40.17, p = 0.01. All PFD patients had arachnoid granulations adjacent to ipsilateral mastoid cell opacification. However, this finding was often subtle and rarely included on the radiology report. There was no significant difference in body mass index, age, presenting complaints, or operative success between the PFD and isolated tegmen defect sCSFL cohorts. Conclusions The posterior fossa is an uncommon location for sCSFL. Careful review of preoperative imaging is often suggestive and can inform surgical approach. PFD patients are similar to those with isolated tegmen-based defects in presentation, comorbidities, and outcomes.

scholarly journals Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Posterior Petrosal Approach

2018 ◽  
Vol 80 (04) ◽  
pp. 338-351 ◽  
Author(s):  
Christopher S. Graffeo ◽  
Maria Peris-Celda ◽  
Avital Perry ◽  
Lucas P. Carlstrom ◽  
Colin L.W. Driscoll ◽  
...  
Keyword(s):  
Skull Base ◽  
Cranial Nerves ◽  
Skin Incision ◽  
Surgical Anatomy ◽  
Muscle Flaps ◽  
Anatomical Dissection ◽  
Superior Petrosal Sinus ◽  
Key Steps ◽  
Retrolabyrinthine Approach ◽  
Burr Holes

Introduction Although numerous anatomical and operative atlases have been published, those that have focused on the skull base either have provided views that are quite difficult to achieve in the operating room to better depict surgical anatomy or are written at the level of an audience with considerable knowledge and experience. Methods Five sides of three formalin-fixed latex-injected specimens were dissected under microscopic magnification. A posterior petrosectomy approach was performed by three neurosurgical residents at different training levels with limited previous experience in anatomical dissection mentored by the senior authors (C. L. W. D. and M. J. L.) and a clinical skull base fellow with additional anatomical dissection experience (M. P. C.). Anatomical dissections were performed until the expected level of dissection quality was achieved to demonstrate each important step of the surgical approach that would be understandable to all trainees of all levels. Following dissection education, representative case applications were reviewed. Results The posterior petrosectomy (also known as presigmoid retrolabyrinthine approach) affords excellent access to cranial nerves III to XI and a diverse array of pathologies. Key steps include positioning and skin incision, scalp and muscle flaps, burr holes, craniotomy flap elevation, superficial mastoidectomy, otic capsule exposure and presigmoid dura decompression, primary presigmoid durotomy, inferior temporal durotomy, superior petrosal sinus ligation, tentorium sectioning, and final exposure. Conclusion The posterior petrosectomy is a challenging approach; thorough operative-style laboratory dissection is essential to provide trainees with a suitable guide. We describe a comprehensive approach to learning this technique, intended to be understandable and usable by a resident audience.

scholarly journals Gross Total Resection of a Recurrent Cavernous Sinus Meningioma through a Combined Transzygomatic Transcavernous and Extended Middle Fossa Approach with Cavernous Carotid Denudation

2021 ◽  
Author(s):  
Yoichi Nonaka ◽  
Naokazu Hayashi ◽  
Takanori Fukushima
Keyword(s):  
Carotid Artery ◽  
Skull Base ◽  
Posterior Fossa ◽  
Cavernous Sinus ◽  
Middle Fossa ◽  
Total Resection ◽  
Middle Fossa Approach ◽  
Cavernous Sinus Meningioma ◽  
Skull Base Meningioma ◽  
The Right

Abstract Objective The aim of this study is to describe surgical management of invasive cavernous sinus meningioma with a combination of skull base approaches. Design This study is an operative video. Results Resection of the recurrent skull base meningioma is still challenging, especially if the tumor involves or encases the carotid artery. In this video, we describe our experience with the successful treatment of a recurrent skull base meningioma, which involved the entire cavernous sinus and the internal carotid artery. A 53-year-old male presented with a 1-year history of progressing right-side complete oculomotor palsy and facial dysesthesia. The patient had previously undergone craniotomy for the right-side petroclival cavernous meningioma (Fig. 1A and B). Total 8 years after the first surgery, the remaining portion of the cavernous sinus grew up and extended into the posterior fossa (Fig. 1C). Then the second surgery was performed to resect only the posterior fossa component (Fig. 1D). However, the follow-up magnetic resonance imaging revealed an aggressive tumor regrowth in 2 years. The tumor occupied the right middle fossa with an extension to the posterior fossa and infratemporal fossa (Fig. 1E and F). We scheduled to perform gross total resection of the tumor through a combined transzygomatic transcavernous and extended middle fossa approach with preparation for vessel reconstruction. Mild adhesion between the tumor and the cavernous carotid artery facilitated complete resection of the intracavernous component of the tumor (Fig. 2A–C). Conclusion A combination of skull base approaches provides multidirectional operative corridors and wide exposure of the skull base lesions.The link to the video can be found at https://youtu.be/DB_WXFeyBvo.

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Retrosigmoid Approach

2019 ◽  
Author(s):  
Christopher S. Graffeo ◽  
Maria Peris-Celda ◽  
Avital Perry ◽  
Lucas P. Carlstrom ◽  
Colin L.W. Driscoll ◽  
...  
Keyword(s):  
Skull Base ◽  
Three Dimensional ◽  
Skin Incision ◽  
Surgical Anatomy ◽  
Retrosigmoid Approach ◽  
Muscle Flaps ◽  
Wide Clinical Application ◽  
Lateral Suboccipital Approach ◽  
Key Steps ◽  
Flap Elevation

Abstract Introduction Neurosurgical anatomy is traditionally taught via anatomic and operative atlases; however, these resources present the skull base using views that emphasize three-dimensional (3D) relationships rather than operative perspectives, and are frequently written above a typical resident's understanding. Our objective is to describe, step-by-step, a retrosigmoid approach dissection, in a way that is educationally valuable for trainees at numerous levels. Methods Six sides of three formalin-fixed latex-injected specimens were dissected under microscopic magnification. A retrosigmoid was performed by each of three neurosurgery residents, under supervision by the senior authors (C.L.W.D. and M.J.L.) and a graduated skull base fellow, neurosurgeon, and neuroanatomist (M.P.C.). Dissections were supplemented with representative case applications. Results The retrosigmoid craniotomy (aka lateral suboccipital approach) affords excellent access to cranial nerve (CN) IV to XII, with corresponding applicability to numerous posterior fossa operations. Key steps include positioning and skin incision, scalp and muscle flaps, burr hole and parasigmoid trough, craniotomy flap elevation, initial durotomy and deep cistern access, completion durotomy, and final exposure. Conclusion The retrosigmoid craniotomy is a workhorse skull base exposure, particularly for lesions located predominantly in the cerebellopontine angle. Operatively oriented neuroanatomy dissections provide trainees with a critical foundation for learning this fundamental skull base technique. We outline a comprehensive approach for neurosurgery residents to develop their familiarity with the retrosigmoid craniotomy in the cadaver laboratory in a way that simultaneously informs rapid learning in the operating room, and an understanding of its potential for wide clinical application to skull base diseases.

scholarly journals Extradural minipterional approach: Evolving indications of the minipterional craniotomy

2020 ◽  
Vol 11 ◽  
pp. 109
Author(s):  
Jorge Mura ◽  
Ivan Perales ◽  
Nicollas Nunes Rabelo ◽  
Rafael Martínez-Pérez ◽  
Tomás Poblete ◽  
...  
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Vascular Lesions ◽  
Middle Fossa ◽  
Skull Base Tumors ◽  
Clinical Series ◽  
Skull Base Lesions ◽  
Anterior Petrosectomy ◽  
Extradural Approach ◽  
Made In

Background: In this paper, we report a clinical series of skull base lesions operated on trough the MiniPT, extending its application to skull base lesions, either using the classical minipterional or a variant, we call extradural minipterional approach (MiniPTEx). Methods: We describe our surgical technique of operating on complex skull base lesions using a minipterional extradural approach. Anterior clinoidectomy, middle fossa peeling, transcavernous, and Kawase approaches were performed as needed. In total, we carried out 24 surgeries: three skull base tumors, 1 Moyamoya case, and 20 giant/complex intracranial aneurysms. All the patients present good neurological result (mRs < 3). Only two patients had paralysis of any cranial nerve and only one patient had a mild hemiparesis. Results: This surgery series there are 24 cases, 10 patients were treated with exclusive MiniPT. MiniPT extradural approach was made in 14 patients. Twelve were treated using pure MiniPTEx approach, 1 patient using transcavernous approach, and in 1 patient, the anterior clinoid was resected with the combination of a MiniPT, a medium fossa peeling, and the Kawase anterior petrosectomy for skull base surgery. Conclusion: We further advance the indications of the MiniPT by extending it to operate on the cranial base tumors or complex vascular lesions without additional morbidity. MiniPT approach may be safely associated with skull base techniques, including anterior and posterior clinoidectomies, peeling of the middle fossa, transcavernous approach, and anterior petrosectomy. The versatility of the MiniPT craniotomy and the feasibility of performing skull base surgery through the MiniPT technique have been demonstrated in this paper.

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