Skull Base Vascular Anatomy of the Infratemporal Fossa Pertinent to Percutaneous Access to the Foramen Ovale for Treatment of Trigeminal Neuralgia: A Comparison of Cadaveric Dissection and Computed Tomography Analysis

Abstract Background Percutaneous glycerol rhizotomy (PGR) is a well-described treatment for trigeminal neuralgia; however, the technique in using surface landmarks and fluoroscopy has not drastically changed since being first introduced. In this paper, we describe a protocol for PGR using computed tomography (CT) guidance based on an experience of over 7 yr and 200 patients. Objective To introduce an approach for PGR using CT guidance and, in doing so, demonstrate possible benefits over the traditional fluoroscopic technique. Methods Using a standard CT scanner, patients are placed supine with head in extension. Barium paste and a CT scout image are used to identify and plan a trajectory to the foramen ovale. A laser localization system built into the CT scanner helps to guide placement of the spinal needle into the foramen ovale. The needle position in the foramen is confirmed with a short-sequence CT scan. Results CT-guided PGR provides multiple benefits over standard fluoroscopy, including improved visualization of the skull base and significant reduction in radiation exposure to the surgeon and staff. Side benefits include improved procedure efficiency, definitive imaging evidence of correct needle placement, and potentially increased patient safety. We have had no significant complications in over 200 patients. CONCLUSION CT-guided PGR is a useful technique for treating trigeminal neuralgia based on better imaging of the skull base, better efficiency of the procedure, and elimination of radiation exposure for the surgeon and staff compared to traditional fluoroscopic based techniques.

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Evaluation of Anatomoradiological Findings on Trigeminal Neuralgia Patients Using Computed Tomography and Cone-Beam Computed Tomography

Diagnostics ◽

10.3390/diagnostics12010073 ◽

2021 ◽

Vol 12 (1) ◽

pp. 73

Author(s):

Seçil Aksoy ◽

Arzu Sayın Şakul ◽

Durmuş İlker Görür ◽

Bayram Ufuk Şakul ◽

Kaan Orhan

Keyword(s):

Computed Tomography ◽

Trigeminal Neuralgia ◽

Cone Beam Ct ◽

Median Plane ◽

Cone Beam ◽

Foramen Ovale ◽

Percutaneous Procedures ◽

The Right ◽

And Control ◽

Supraorbital Foramen

The study aimed to establish and evaluate anatomoradiological landmarks in trigeminal neuralgia patients using computed tomography (CT) and cone-beam CT. CT images of 40 trigeminal neuralgia (TN) and 40 healthy individuals were retrospectively analyzed and enrolled in the study. The width and length of the foramen rotundum (FR), foramen ovale (FO), foramen supraorbitale, and infraorbitale were measured. The distances between these foramen, between these foramen to the median plane, and between the superior orbital fissure, FO, and FR to clinoid processes were also measured bilaterally. Variations were evaluated according to groups. Significant differences were found for width and length of the foramen ovale, length of the foramen supraorbitale, and infraorbitale between TN and control subjects (p < 0.05). On both sides, FO gets narrower and the length of the infraorbital and supraorbital foramen shortens in the TN group. In most of the control patients, the plane which passes through the infraorbital and supraorbital foramen intersects with impression trigeminale; 70% on the right-side, and 67% in the left-side TN groups. This plane does not intersect with impression trigeminale and deviates in certain degrees. The determination of specific landmarks allows customization to individual patient anatomy and may help the surgeon achieve a more selective effect with a variety of percutaneous procedures in trigeminal neuralgia patients.

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Dorsal Preservation Rhinoplasty: Core Beam Computed Tomography Analysis of the Nasal Vault, Septum, and Skull Base—Its Role in Surgical Planning

Facial Plastic Surgery ◽

10.1055/s-0040-1712538 ◽

2020 ◽

Vol 36 (03) ◽

pp. 329-334

Author(s):

Amir Sadri ◽

Charles East ◽

Lydia Badia ◽

Yves Saban

Keyword(s):

Computed Tomography ◽

Skull Base ◽

Frontal Sinus ◽

Surgical Planning ◽

Cribriform Plate ◽

Nasal Vault ◽

Tomography Analysis

AbstractDorsal preservation rhinoplasty in cases of a convex or overprojected noses has significant advantages over resection and reconstruction of the dorsum. Analysis of the subdorsal septum in relation to the radix osteotomy to achieve a drop or hinge of the natural dorsum is important in avoiding possible complications involving the skull base, frontal sinus, and subsequent radix position. In the majority of patients, simple cut release of the perpendicular plate rather than resection superiorly may be necessary where the quadrangular cartilage junction with the perpendicular plate is caudal to the radix osteotomy. Computed tomography is helpful in delineating this position as well as providing information on the frontal sinus and position of the cribriform plate prerhinoplasty.

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Ossification of the pterygoalar and pterygospinous ligaments: a computed tomography analysis of infratemporal fossa anatomical variants relevant to percutaneous trigeminal rhizotomy

Journal of Neurosurgery ◽

10.3171/2019.2.jns182709 ◽

2020 ◽

Vol 132 (6) ◽

pp. 1942-1951

Author(s):

Tomasz Matys ◽

Tariq Ali ◽

Fulvio Zaccagna ◽

Damiano G. Barone ◽

Ramez W. Kirollos ◽

...

Keyword(s):

Computed Tomography ◽

Skull Base ◽

Infratemporal Fossa ◽

Maximum Intensity Projection ◽

Contralateral Side ◽

Surgical Anatomy ◽

Ct Scans ◽

Surgical Approaches ◽

Cross Sectional ◽

Radiological Anatomy

OBJECTIVEOssification of pterygoalar and pterygospinous ligaments traversing the superior aspect of the infratemporal fossa results in formation of osseous bars that can obstruct percutaneous needle access to the trigeminal ganglion through the foramen ovale (FO), interfere with lateral mandibular nerve block, and impede transzygomatic surgical approaches. Presence of these ligaments has been studied on dry skulls, but description of their radiological anatomy is scarce, in particular on cross-sectional imaging. The aim of this study was to describe visualization of pterygoalar and pterygospinous bars on computed tomography (CT) and to review their prevalence and clinical significance.METHODSThe authors retrospectively reviewed 200 helical sinonasal CT scans by analyzing 0.75- to 1.0-mm axial images, maximum intensity projection (MIP) reconstructions, and volume rendered (VR) images, including views along the anticipated axis of the needle in percutaneous Hartel and submandibular approaches to the FO.RESULTSOssified pterygoalar and pterygospinous ligaments were readily identifiable on CT scans. An ossified pterygoalar ligament was demonstrated in 10 patients, including 1 individual with bilateral complete ossification (0.5%), 4 patients with unilateral complete ossification (2.0%), and 5 with incomplete unilateral ossification (2.5%). Nearly all patients with pterygoalar bars were male (90%, p < 0.01). An ossified pterygospinous ligament was seen in 35 patients, including 2 individuals with bilateral complete (1.0%), 8 with unilateral complete (4%), 8 with bilateral incomplete (4.0%), 12 with bilateral incomplete (6.0%) ossification, and 5 (2.5%) with mixed ossification (complete on one side and incomplete on the contralateral side). All pterygoalar bars interfered with a hypothetical needle access to the FO using the Hartel approach but not the submandibular approach. In contrast, 54% of complete and 24% of incomplete pterygospinous bars impeded the submandibular approach to the FO, without affecting the Hartel approach.CONCLUSIONSThis study provides the first detailed description of cross-sectional radiological and applied surgical anatomy of pterygoalar and pterygospinous bars. Our data are clinically useful during skull base imaging to predict potential obstacles to percutaneous cannulation of the FO and assist in the choice of approach, as these two variants differentially impede the Hartel and submandibular access routes. Our results can also be useful in planning surgical approaches to the skull base through the infratemporal fossa.

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High-resolution computed tomography analysis of the medial infratemporal fossa: a pilot study

International Forum of Allergy & Rhinology ◽

10.1002/alr.21045 ◽

2012 ◽

Vol 2 (5) ◽

pp. 432-434 ◽

Cited By ~ 1

Author(s):

Jean Anderson Eloy ◽

Samuel A. Reyes ◽

Ross Germani ◽

James K. Liu ◽

Roy R. Casiano

Keyword(s):

Computed Tomography ◽

Pilot Study ◽

High Resolution ◽

Infratemporal Fossa ◽

High Resolution Computed Tomography ◽

Tomography Analysis

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Computed Tomography - Directed Fine Needle Aspiration of Skull Base Parapharyngeal and Infratemporal Fossa Masses

Skull Base ◽

10.1055/s-2008-1058916 ◽

1995 ◽

Vol 5 (04) ◽

pp. 199-205 ◽

Cited By ~ 5

Author(s):

Michael Spearman ◽

Hugh Curtin ◽

David Dusenbery ◽

Ivo P. Janecka ◽

Edna L. Reyna

Keyword(s):

Computed Tomography ◽

Skull Base ◽

Fine Needle Aspiration ◽

Infratemporal Fossa ◽

Needle Aspiration ◽

Fine Needle

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Expanded Endonasal Approach for Resection of Extradural Infratemporal Fossa Trigeminal Schwannoma: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa102 ◽

2020 ◽

Vol 19 (4) ◽

pp. E396-E397

Author(s):

Karam Asmaro ◽

Jack Rock ◽

John Craig

Keyword(s):

Maxillary Sinus ◽

Skull Base ◽

Infratemporal Fossa ◽

Posterior Wall ◽

Sinus Surgery ◽

Csf Leak ◽

Foramen Ovale ◽

Nasoseptal Flap ◽

Carotid Canal ◽

Expanded Endonasal Approach

Abstract The infratemporal fossa (ITF) is bounded superiorly by the skull base, specifically the greater wing of the sphenoid, which contains foramen ovale. It is bordered posteriorly by the temporal bone, including the petrous portion of the carotid canal, anteriorly by the posterior wall of the maxillary sinus, laterally by the mandible, and medially by the pterygoid body and lateral pterygoid plate.1-3 In this video, we report a case of a rare, exclusively extradural, schwannoma originating from the third division of the trigeminal nerve with a widened foramen ovale at the skull base. The tumor filled the ITF and extended laterally just through the sigmoid notch of the mandible. The patient complained of left cheek and lower jaw numbness and intermittent left jaw spasms. The tumor was deemed appropriate for endoscopic resection. To access the ITF, left-sided endoscopic sinus surgery, a modified endoscopic Denker's approach,4 and posterior nasal septectomy were first performed. A nasoseptal flap was also harvested in case an intraoperative cerebrospinal fluid (CSF) leak required repair. Dissection was carried out through the posterior wall of the maxillary sinus and pterygopalatine fossa to reach the ITF. Tumor resection was achieved through a 2-surgeon, 4-handed approach in which appropriate traction and countertraction were carefully applied to tease the tumor away from the skull base and dehiscent carotid canal. No CSF leak or carotid injury occurred, and the posterior maxillary sinus wall defect was repaired with the nasoseptal flap. The patient did well postoperatively. The patient consented to the procedure in a standard fashion.

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A Segmentation Method of Foramen Ovale Based on Multiatlas

Computational and Mathematical Methods in Medicine ◽

10.1155/2021/5221111 ◽

2021 ◽

Vol 2021 ◽

pp. 1-10

Author(s):

Jiashi Zhao ◽

Huatao Ge ◽

Wei He ◽

Yanfang Li ◽

Weili Shi ◽

...

Keyword(s):

Trigeminal Neuralgia ◽

Skull Base ◽

Clinical Work ◽

Ct Scans ◽

Foramen Ovale ◽

Limited Data ◽

Segmentation Method ◽

Data Set ◽

Computer Aided ◽

Complex Computer

Trigeminal neuralgia is a neurological disease. It is often treated by puncturing the trigeminal nerve through the skin and the oval foramen of the skull to selectively destroy the pain nerve. The process of puncture operation is difficult because the morphology of the foramen ovale in the skull base is varied and the surrounding anatomical structure is complex. Computer-aided puncture guidance technology is extremely valuable for the treatment of trigeminal neuralgia. Computer-aided guidance can help doctors determine the puncture target by accurately locating the foramen ovale in the skull base. Foramen ovale segmentation is a prerequisite for locating but is a tedious and error-prone task if done manually. In this paper, we present an image segmentation solution based on the multiatlas method that automatically segments the foramen ovale. We developed a data set of 30 CT scans containing 20 foramen ovale atlas and 10 CT scans for testing. Our approach can perform foramen ovale segmentation in puncture operation scenarios based solely on limited data. We propose to utilize this method as an enabler in clinical work.

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A Novel Method of Locating Foramen Ovale for Percutaneous Approaches to the Trigeminal Ganglion

January 2018 - Pain Physician ◽

10.36076/ppj/2019.22.e345 ◽

2019 ◽

Vol 4 (22;4) ◽

pp. E345-E350

Author(s):

Sung Hyun Lee

Keyword(s):

Computed Tomography ◽

Trigeminal Neuralgia ◽

Trigeminal Ganglion ◽

Surgical Approaches ◽

Fluoroscopic Guidance ◽

Foramen Ovale ◽

Anatomic Landmarks ◽

3 Dimensional ◽

Percutaneous Procedures ◽

Novel Method

Background: For patients with trigeminal neuralgia who do not respond to medication and for whom surgical approaches are too risky, percutaneous procedures targeting the trigeminal ganglion are the current standard treatment. Percutaneous procedures are performed via the transoval approach under radiologic guidance. Identification of the foramen ovale (FO) under fluoroscopic guidance is an important part of determining the success or failure of the procedures. Objectives: Previous studies have described how to visualize the FO under fluoroscopic guidance, but those methods are limited by poor reproducibility. In this study, we have investigated how to visualize the FO clearly and easily under fluoroscopic guidance. Study Design: Retrospective analysis. Setting: University hospital in Korea. Methods: Seventy-two 3-dimensional facial computed tomography scans without anatomic abnormalities of the skull base were analyzed for verifying the novel method. First, the mandibular angle and the occipital cortical line were overlapped and then turned by 15° oblique rotation using the software package. After these manipulations, the visualization of the FO was graded according to a 4-point scale (0: poor; 1: fair; 2: good; 3: excellent), and the inferior transfacial and oblique angles were measured. Results: This enabled clear visualization of the FO. The mean visual grade of 54 right and 46 left FO (total 100) was 2.74 (0: poor; 1: fair; 2: good; 3: excellent). All recorded FOs had at least grade 2 visibility. Limitations: This study is lacking application in clinical practice and comparative data to the submental view. Conclusions: The mandible angle and the occipital cortex line are obvious anatomic landmarks and are visible even to nonexperienced practitioners. Therefore, our method using these anatomic landmarks can improve the reproducibility and accuracy of FO visualization. Key words: Trigeminal neuralgia, foramen ovale, trigeminal ganglion, 3-dimensional (3D) facial computed tomography (CT) scans

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