Endoscopic Endonasal Approaches to the Clivus with No Violation of the Nasopharynx: Surgical Anatomy and Clinical Illustration

Lateral sphenoid encephaloceles of the Sternberg canal are rare entities and usually present with spontaneous CSF rhinorrhea. Traditionally, these were treated via transcranial approaches, which can be challenging given the deep location of these lesions. However, with advancements in endoscopic skull base surgery, including improved surgical exposures, angled endoscopes and instruments, and novel repair techniques, these encephaloceles can be resected and successfully repaired with purely endoscopic endonasal approaches. In this report, the authors review the endoscopic endonasal transpterygoid approach to the lateral recess of the sphenoid sinus for repair of temporal lobe encephaloceles, including an overview of the surgical anatomy from an endoscopic perspective, and describe the technical operative nuances and surgical pearls for these cases. The authors also present 4 new cases of lateral sphenoid recess encephaloceles that were successfully treated using this approach.

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Endoscopic endonasal transoculomotor triangle approach for adenomas invading the parapeduncular space: surgical anatomy, technical nuances, and case series

Journal of Neurosurgery ◽

10.3171/2017.10.jns17779 ◽

2019 ◽

Vol 130 (4) ◽

pp. 1304-1314 ◽

Cited By ~ 7

Author(s):

Cristian Ferrareze Nunes ◽

Stefan Lieber ◽

Huy Q. Truong ◽

Georgios Zenonos ◽

Eric W. Wang ◽

...

Keyword(s):

Cavernous Sinus ◽

Case Series ◽

Surgical Anatomy ◽

Oculomotor Nerve ◽

Oculomotor Nerve Palsy ◽

Tumor Extension ◽

Endoscopic Endonasal ◽

Transcranial Approach ◽

Surgical Corridor ◽

Dural Opening

OBJECTIVEPituitary adenomas may extend into the parapeduncular space by invading through the roof of the cavernous sinus. Currently, a transcranial approach is the preferred choice, with or without the combination of an endonasal approach. In this paper the authors present a novel surgical approach that takes advantage of the natural corridor provided by the tumor to further open the oculomotor triangle and resect tumor extension into the parapeduncular space.METHODSSix injected specimens were used to demonstrate in detail the surgical anatomy related to the approach. Four cases in which the proposed approach was used were retrospectively reviewed.RESULTSFrom a technical perspective, the first step involves accessing the superior compartment of the cavernous sinus. The interclinoid ligament should be identified and the dura forming the oculomotor triangle exposed. The oculomotor dural opening may be then extended posteriorly toward the posterior petroclinoidal ligament and inferolaterally toward the anterior petroclinoidal ligament. The oculomotor nerve should then be identified; in this series it was displaced superomedially in all 4 cases. The posterior communicating artery should also be identified to avoid its injury. In all 4 cases, the tumor invading the parapeduncular space was completely removed. There were no vascular injuries and only 1 patient had a partial oculomotor nerve palsy that completely resolved in 2 weeks.CONCLUSIONSThe endoscopic endonasal transoculomotor approach is an original alternative for removal of tumor extension into the parapeduncular space in a single procedure. The surgical corridor is increased by opening the dura of the oculomotor triangle and by working below and lateral to the cisternal segment of the oculomotor nerve.

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Endoscopic Endonasal Approaches to the Clivus with No Violation of the Nasopharynx: Surgical Anatomy and Clinical Illustration

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1729905 ◽

2021 ◽

Author(s):

Carlos D. Pinheiro-Neto ◽

Laura Salgado-Lopez ◽

Luciano C.P.C. Leonel ◽

Serdar O. Aydin ◽

Maria Peris-Celda

Keyword(s):

Posterior Fossa ◽

Cerebrospinal Fluid Leak ◽

Craniovertebral Junction ◽

Foramen Magnum ◽

Surgical Anatomy ◽

Csf Leak ◽

Surgical Approaches ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal

Abstract Background Despite the use of vascularized intranasal flaps, endoscopic endonasal posterior fossa defects remain surgically challenging with high rates of postoperative cerebrospinal fluid leak. Objective The aim of the study is to describe a novel surgical technique that allows complete drilling of the clivus and exposure of the craniovertebral junction with preservation of the nasopharynx. Methods Two formalin-fixed latex-injected anatomical specimens were used to confirm feasibility of the technique. Two surgical approaches were used: sole endoscopic endonasal approach and transnasion approach. The sole endonasal approach was used in a patient with a petroclival meningioma. Results In both anatomical dissections, the inferior clivectomy with exposure of the foramen magnum was achieved with a sole endoscopic endonasal approach. The addition of the transnasion approach helped to complete drilling of the inferior border of the foramen magnum and exposure of the arch of C1. Conclusion This study shows the anatomical feasibility of total clivectomy and exposure of the craniovertebral junction with preservation of the nasopharynx. A more favorable anatomical posterior fossa defect for the reconstruction is achieved with this technique. Further clinical studies are needed to assess if this change would impact the postoperative CSF leak rate.

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Endoscopic endonasal transcavernous approach for invasive corticotroph pituitary adenoma

Neurosurgical Focus: Video ◽

10.3171/2020.4.focusvid.19949 ◽

2020 ◽

Vol 2 (2) ◽

pp. V2

Author(s):

Ming-Ying Lan ◽

Wei-Hsin Wang

Keyword(s):

Cavernous Sinus ◽

Diagnostic Tests ◽

Tumor Resection ◽

Cranial Nerves ◽

Surgical Anatomy ◽

Total Resection ◽

Endoscopic Endonasal ◽

Cavernous Sinus Invasion ◽

The Right

This is a 37-year-old woman who presented with weight gain, a moon-shaped face, and muscle weakness for 4 months. Cushing’s disease was confirmed after a series of diagnostic tests. MRI demonstrated a pituitary macroadenoma with right cavernous sinus invasion and encasement of the right ICA. An endoscopic endonasal approach was performed, and gross-total resection could be achieved without injury of the cranial nerves. The Cushing’s syndrome improved gradually after the surgery. Histopathology revealed a corticotroph adenoma. In this surgical video, we demonstrate the strategies of tumor resection according to a surgical anatomy-based classification of the cavernous sinus from an endonasal perspective.The video can be found here: https://youtu.be/aNXFRdGfjpI.

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Endoscopic Endonasal Supraoptic and Infraoptic Approaches for Complex “Parasuprasellar” Lesions: Surgical Anatomy, Technique Nuances, and Case Series

10.21203/rs.3.rs-622199/v2 ◽

2021 ◽

Author(s):

You Yuan Bao ◽

You Qing Yang ◽

Lin Zhou ◽

Shen Hao Xie ◽

Xiao Wu ◽

...

Keyword(s):

Surgical Simulation ◽

Tumor Resection ◽

Case Series ◽

Surgical Anatomy ◽

Anterior Clinoid Process ◽

Endoscopic Endonasal ◽

Multiple Aneurysms ◽

Suprasellar Region ◽

Midline Approach ◽

Planum Sphenoidale

Abstract Surgical management of lesions involving the lateral area of the suprasellar region, including the lateral aspect of the planum sphenoidale and a tight junction region of the optic canal (OC), the anterior clinoid process (ACP), and the internal carotid artery (ICA) and its dural rings, is extremely challenging. Here, the authors introduce two novels endoscopic endonasal supraoptic (EESO) and endoscopic endonasal infraoptic (EEIO) approaches to access these regions, namely, “parasuprasellar” area. Surgical simulation of the EESO and EEIO approaches to the parasuprasellar area was conducted in 5 silicon-injected specimens. The same techniques were applied in 12 patients involving the parasuprasellar area.The EESO and EEIO approaches can be used independently or in combination, but are more often employed as a complement to the endoscopic endonasal midline approach and transcavernous approach. In clinical application, the EESO and EEIO approaches were successfully performed in 12 patients harboring tumors and multiple aneurysms involving the parasuprasellar area. Gross total and subtotal tumor resection were achieved in 9 patients and 1 patient, respectively. For two patients with multiple aneurysms, the lesions were clipped selectively according to location and size. Visual acuity improved in 7 patients, remained stable in 4, and deteriorated in only 1. No postoperative intracranial infection or ICA injury occurred in this series. The EESO and EEIO approaches can be combined with the current endoscopic endonasal midline approach and transcavernous approach to remove extensive pathologies involving the intrasellar, suprasellar, sphenoid, and cavernous sinuses and even bifurcation of the ICA.

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Endoscopic Anatomy of the Zygomatic Nerve: Implications for the Endoscopic Transmaxillary Approach

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1739237 ◽

2021 ◽

Author(s):

Yuanzhi Xu ◽

Maximiliano Alberto Nunez ◽

Ahmed Mohyeldin ◽

Juan C. Fernandez-Miranda ◽

Aaron A. Cohen-Gadol

Keyword(s):

Endoscopic Surgery ◽

Surgical Anatomy ◽

Exit Point ◽

Endoscopic Endonasal ◽

Maxillary Nerve ◽

Endonasal Endoscopic Surgery ◽

Point Of Entry ◽

Facial Numbness ◽

Course Length ◽

Müller’S Muscle

Abstract Background Understanding the anatomic features of the zygomatic nerve is critical for performing the endoscopic transmaxillary approach properly. Injury to the zygomatic nerve can result in facial numbness and corneal problems. Objective To evaluate the surgical anatomy of the zygomatic nerve and its segments from an endoscopic endonasal perspective for clinical implications of performing the endoscopic transmaxillary approach. Methods The origin, course, length, and segments of the zygomatic nerve were studied in four specimens from an endonasal perspective. Results The zygomatic nerve arises 4.1 ± 1.7 mm from the foramen rotundum of the maxillary nerve in the superolateral pterygopalatine fossa (PPF). According to its anatomic region in endonasal endoscopic surgery, we divided the zygomatic nerve into two segments: the PPF segment, from origin to the point of entry under Muller's muscle, which runs superolaterally to the inferior orbital fissure (IOF) (length, 4.6 ± 1.3 mm), and the IOF segment, starting at the entry point in Muller's muscle and terminating at the exit point in the IOF, which travels between Muller's muscle and the great wing of the sphenoid bone (length, 19.6 ± 3.6 mm). In the transmaxillary approach, the zygomatic nerve is a critical landmark in the superolateral PPF. Conclusion The zygomatic nerve travels in the PPF and the IOF; better visualization and preservation of this nerve during endonasal endoscopic surgery are crucial for successful outcomes.

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