Subtemporal Approach and Its Infratentorial Extension: Review and a Comparative Analysis of Different Techniques

2022 ◽  
Author(s):  
Tomasz Andrzej Dziedzic ◽  
Kumar Abhinav ◽  
Juan C. Fernandez-Miranda
Keyword(s):  
Human Head ◽  
Petrous Apex ◽  
Surgical Approaches ◽  
Cerebral Peduncle ◽  
Subtemporal Approach ◽  
Prepontine Cistern ◽  
Surgical Access ◽  
Anterior Petrosectomy ◽  
Tentorial Incisura ◽  
Selection Of

Abstract Introduction Surgical resection of lesions occupying the incisural space is challenging. In a comparative fashion, we aimed to describe the anatomy and surgical approaches to the tentorial incisura and to the rostral brainstem via the intradural subtemporal approach and its infratentorial extensions. Methods Six fresh human head specimens (12 sides) were prepared for the microscopic dissection of the tentorial incisura using the intradural subtemporal approach and its infratentorial extensions. Endoscope was used to examine the anatomy of the region inadequately exposed with the microscope. Image-guided navigation was used to confirm bony structures visualized around the petrous apex. Results Standard subtemporal approach provides surgical access to the supratentorial brainstem above the pontomesencephalic sulcus and to the lateral surface of the cerebral peduncle. The linear or triangular tentorial divisions can provide access to the infratentorial space below the pontomesencephalic sulcus. The triangular tentorial flap in comparison with the linear incision obstructs the exposure of anterior incisural space and of the prepontine cistern. Visualization of the brainstem below the trigeminal nerve can be achieved by the anterior petrosectomy. Conclusion Infratentorial extension of the intradural subtemporal approach is technically demanding due to critical neurovascular structures and a relatively narrow corridor. In-depth anatomical knowledge is essential for the selection of the appropriate operative approach and safe surgical resections of lesions.

Surgical Approaches to Aneurysms of the Vertebral and Basilar Arteries

Neurosurgery ◽  
1988 ◽  
Vol 23 (2) ◽  
pp. 203-208 ◽  
Author(s):  
Robert A. Solomon ◽  
Bennett M. Stein
Keyword(s):  
Surgical Treatment ◽  
Life Style ◽  
Petrous Apex ◽  
Surgical Approaches ◽  
Lateral Sinus ◽  
Basilar Arteries ◽  
Lateral Suboccipital Approach ◽  
Suboccipital Approach ◽  
Supratentorial Approach ◽  
Selection Of

ABSTRACT This report details the surgical treatment of 44 patients with aneurysms of the vertebral and basilar arteries. Three different surgical approaches were utilized depending on the location of the aneurysm. These were an anterior supratentorial approach, a lateral suboccipital approach, and a combined supratentorial and infratentorial approach along the petrous apex, with section of the lateral sinus and the tentorium. Using these operative exposures, aneurysms located anywhere on the vertebral-basilar arteries may be safely visualized and clipped. In this series, 1 patient died, 4 other patients had significant, long-lasting morbidity as a result of operation, and 32 patients returned to work and a normal life-style. These data support operative intervention under proper conditions and with selection of the correct exposures for the treatment of vertebral-basilar aneurysms.

The Lateral Facial Approach to the Nasopharynx and Infratemporal Fossa

1988 ◽  
Vol 99 (3) ◽  
pp. 321-325 ◽  
Author(s):  
George A. Gates
Keyword(s):  
Single Case ◽  
Infratemporal Fossa ◽  
Operating Time ◽  
Petrous Apex ◽  
Surgical Approaches ◽  
Intracranial Extension ◽  
Surgical Access ◽  
Technical Control ◽  
Ethmoid Sinuses ◽  
And Control

Surgical access to the nasopharynx and infratemporal fossa is restricted by the bony structures that support and define these areas. Traditional surgical approaches to the nasopharynx for removal of benign neoplasms follow three directions: (1) the anterior route via the nasal cavity and the maxillary and, if necessary, the ethmoid sinuses; (2) the inferior route through the palate; and (3) the anterolateral retromaxillary pathway via the gingivobuccal sulcus into the pterygoid space. These approaches provide fair access, but limited visibility and little technical control of the neurovascular supply. For the small- to medium-sized tumor, the experienced surgeon is able to successfully manage the majority of cases using these approaches, singly or in combination. However, in patients with larger tumors—when recurrence is more common—approaches offering greater visualization have been developed, such as Panje's facial bifiap,1 Mann's transmaxillary,2 and Fisch's transtemporal.3 These provide better access and control at the cost of increased locoregional morbidity, long operating time, and considerable technical complexity. I have developed a simpler, more direct surgical approach that combines the exposure concepts of the head and neck surgeon with the microsurgical techniques of the otosurgeon. It has been applied to eight cases, with minimal morbidity and excellent results, and appears to be the procedure of choice for cases of angiofibroma with early intracranial extension. Subsequently, a similar approach, developed previously by Holliday,4 has been published in which access into the anterior temporal lobe, petrous apex, and clivus are gained. In this report, I describe and illustrate the anatomic and technical considerations of this approach and report a single case in which it was first applied.

Current Strategies in the Management of Spinal Metastatic Disease

Swiss Surgery ◽  
2003 ◽  
Vol 9 (2) ◽  
pp. 55-62 ◽  
Author(s):  
Bartanusz ◽  
Porchet
Keyword(s):  
Spinal Cord ◽  
Surgical Techniques ◽  
Cord Compression ◽  
Treatment Modalities ◽  
Surgical Approaches ◽  
Spinal Stabilization ◽  
Management Algorithm ◽  
Specific Manner ◽  
Extensive Surgery ◽  
Selection Of

The treatment of metastatic spinal cord compression is complex. The three treatment modalities that are currently applied (in a histologically non-specific manner) are surgery, radiotherapy and the administration of steroids. The development of new spinal instrumentations and surgical approaches considerably changed the extent of therapeutic options in this field. These new surgical techniques have made it possible to resect these tumours totally, with subsequent vertebral reconstruction and spinal stabilization. In this respect, it is important to clearly identify those patients who can benefit from such an extensive surgery. We present our management algorithm to help select patients for surgery and at the same time identifying those for whom primary non-surgical therapy would be indicated. The retrospective review of surgically treated patients in our department in the last four years reveals a meagre application of conventional guidelines for the selection of the appropriate operative approach in the surgical management of these patients. The reasons for this discrepancy are discussed.

Revising the Indications of Transtemporal Surgical Approaches in the Modern Endoscopic Era of Skull Base Surgery: A Dying Art

2020 ◽  
Author(s):  
Ravi Sankar Manogaran ◽  
Raj Kumar ◽  
Arulalan Mathialagan ◽  
Anant Mehrotra ◽  
Amit Keshri ◽  
...  
Keyword(s):  
Skull Base ◽  
Surgical Approach ◽  
Nerve Palsy ◽  
Tertiary Care ◽  
Surgical Approaches ◽  
Microsurgical Anatomy ◽  
Complete Excision ◽  
Lateral Skull Base ◽  
The Individual ◽  
Selection Of

Abstract Objectives The aim of the study is to emphasize and explore the possible transtemporal approaches for spectrum of complicated lateral skull base pathologies. Design Retrospective analysis of complicated lateral skull base pathologies was managed in our institute between January 2017 and December 2019. Setting The study was conducted in a tertiary care referral center. Main Outcome Measures The study focused on the selection of approach based on site and extent of the pathology, the surgical nuances for each approach, and the associated complications. Results A total of 10 different pathologies of the lateral skull base were managed by different transtemporal approaches. The most common complication encountered was facial nerve palsy (43%, n = 6). Other complications included cerebrospinal fluid (CSF) collection (15%, n = 2), cosmetic deformity (24%, n = 4), petrous internal carotid artery injury (7%, n = 1), and hypoglossal nerve palsy (7%, n = 1). The cosmetic deformity included flap necrosis (n = 2) and postoperative bony defects leading to contour defects of the scalp (n = 2). Conclusion Surgical approach should be tailored based on the individual basis, to obtain adequate exposure and complete excision. Selection of appropriate surgical approach should also be based on the training and preference of the operating surgeon. Whenever necessary, combined surgical approaches facilitating full tumor exposure are recommended so that complete tumor excision is feasible. This requires a multidisciplinary team comprising neurosurgeons, neuro-otologist, neuroanesthetist, and plastic surgeons. The surgeon must know precise microsurgical anatomy to preserve the adjacent nerves and vessels, which is necessary for better surgical outcomes.

Irresectable tumours of the temporal bone

1987 ◽  
Vol 101 (5) ◽  
pp. 432-442 ◽  
Author(s):  
R. E. Quiney ◽  
L. M. Flood
Keyword(s):  
Temporal Bone ◽  
Case Reports ◽  
Sporadic Case ◽  
Petrous Apex ◽  
Surgical Approaches ◽  
Total Removal ◽  
Inaccessible Area ◽  
History Of ◽  
Petrous Temporal Bone

AbstractSporadic case reports and the few published series of expanding lesions of the deep petrous temporal bone propose a variety of surgical approaches to ensure excision. All such surgery represents a compromise between exposure adequate for total removal and avoidance of further neurological deficit. Unfortunately pathology in the petrous apex evolves relatively silently and diagnosis is delayed. In many cases total excision is impossible. We present a series of patients presenting with advanced tumours of the deep petrous temporal bone in order to illustrate the spectrum of disease encountered, the limited role of surgery and the natural history of irresectable pathology in this remote and inaccessible area.

Custom-tailored transdural anterior transpetrosal approach to ventral pons and retroclival regions

2006 ◽  
Vol 104 (1) ◽  
pp. 38-46 ◽  
Author(s):  
Hans-Jakob Steiger ◽  
Daniel Hänggi ◽  
Walter Stummer ◽  
Peter A. Winkler
Keyword(s):  
Carotid Artery ◽  
Cranial Nerves ◽  
Extent Of Resection ◽  
Venous Congestion ◽  
Petrous Apex ◽  
Anterior Transpetrosal Approach ◽  
Target Field ◽  
Custom Made ◽  
Anterior Petrosectomy ◽  
Spinal Catheter

Object The extradural anterior petrosectomy approach to the pons and midbasilar artery (mid-BA) has the main disadvantage that the extent of resection of the petrous apex cannot be as minimal as desired given that the surgical target field is not visible during bone removal. Unnecessary or excessive drilling poses the risk of injury to the internal carotid artery, vestibulocochlear organ, and seventh and eighth cranial nerves. The use of a custom-tailored transdural anterior transpetrosal approach can potentially avoid these pitfalls. Methods A technique for a transdural anterior petrosectomy was developed in the operating theater and anatomy laboratory. Following a subtemporal craniotomy and basal opening of the dura mater, the vein of Labbé is first identified and protected. Cerebrospinal fluid ([CSF] 50–100 ml) is drained via a spinal catheter. The tent is incised behind the entrance of the trochlear nerve toward the superior petrosal sinus (SPS), which is coagulated and divided. The dura is stripped from the petrous pyramid. Drilling starts at the petrous ridge and proceeds laterally and ventrally. The trigeminal nerve is unroofed. The internal acoustic meatus is identified and drilling is continued laterally as needed. The bone of the Kawase triangle toward the clivus can be removed down to the inferior petrosal sinus if necessary. Anterior exposure can be extended to the carotid artery if required. It is only exceptionally necessary to follow the greater superior petrosal nerve toward the geniculate ganglion and to expose the length of the internal acoustic canal. The modified transdural anterior petrosectomy exposure has been used in nine patients—two with a mid-BA aneurysm, two with a dural arteriovenous fistula, one with a pontine glioma, three with a pontine cavernoma, and one with a pontine abscess. In one patient with a mid-BA aneurysm, subcutaneous CSF collection occurred during the postoperative period. No CSF fistula or approach-related cranial nerve deficit developed in any of these patients. There was no retraction injury or venous congestion of the temporal lobe nor any venous congestion due to the obliteration of the SPS or the petrosal vein. Conclusions The custom-made transdural anterior petrosectomy appears to be a feasible alternative to the formal extradural approach.

scholarly journals Analysis of Approaches in the Microsurgical Treatment of 102 Cases of Petroclival Meningioma in a Single Center

2021 ◽  
Vol 12 ◽  
Author(s):  
Yazhou Lin ◽  
Qiang Gao ◽  
Huiping Jin ◽  
Nana Wang ◽  
Dingkang Xu ◽  
...  
Keyword(s):  
Attachment Site ◽  
Petrous Apex ◽  
Surgical Approaches ◽  
Karnofsky Performance Scale ◽  
Therapeutic Effects ◽  
Single Center ◽  
Petroclival Meningioma ◽  
Tumor Subtypes ◽  
Significant Difference

Objectives: We identified the optimal approaches for treating the diverse tumor subtypes of petroclival meningioma (PM) by analyzing the clinical benefits of various surgical approaches adopted for each subtype.Methods: Tumors in 102 PM patients from a single center who underwent surgical treatment were classified as upper clivus (UC), cavernous sinus (CS), tentorium (TE), or petrous apex (PA) types based on the attachment site of the tumor base and the displacement of the trigeminal nerve. The therapeutic effects of different surgical approaches among the subtypes were evaluated according to the patient outcomes.Results: The subtemporal (33.33%), retrosigmoid (16.67%), and Kawase approaches (50%) were used for the UC type. Simpson I/II resection was achieved in 46.66% of patients with the Kawase approach. Significant differences were found between the other two approaches (P = 0.044) and in the follow-up Karnofsky performance scale (KPS) scores (P = 0.008). The subtemporal (60%) and Kawase approaches (40%) were used for the CS type; neither approach achieved Simpson I/II resection. The retrosigmoid (25.81%) and Kawase approaches (74.19%) were used for the TE type. The Simpson I/II resection rates of the two approaches were 55.55 and 86.95%, respectively, and a significant difference was observed between them (P = 0.039). The retrosigmoid (43.75%) and Kawase approaches (56.25%) were used for the PA type. The Simpson I/II resection rates of the two approaches were 31.25 and 50%, respectively. The resection degrees of the two approaches and the KPS scores at follow-up were significantly different (P = 0.034).Conclusion: The individual microsurgical approaches adopted for the various PM tumor subtypes can provide maximal safe resection and good KPS scores. The Kawase approach is more suitable for PM, especially for UC- and PA-type PM tumors.

scholarly journals Skull Base Trauma: Clinical Considerations in Evaluation and Diagnosis and Review of Management Techniques and Surgical Approaches

2017 ◽  
Vol 31 (04) ◽  
pp. 177-188 ◽  
Author(s):  
Soroush Farnoosh ◽  
Robert Kellman ◽  
Sherard Tatum ◽  
Jacob Feldman
Keyword(s):  
Skull Base ◽  
Surgical Approaches ◽  
Trauma Patients ◽  
Traumatic Injuries ◽  
Surgical Access ◽  
Radiographic Testing ◽  
Cranial Nerve Injury ◽  
Cranial Fossa ◽  
Skull Base Anatomy ◽  
Neurovascular Structures

AbstractTraumatic injuries to the skull base can involve critical neurovascular structures and present with symptoms and signs that must be recognized by physicians tasked with management of trauma patients. This article provides a review of skull base anatomy and outlines demographic features in skull base trauma. The manifestations of various skull base injuries, including CSF leaks, facial paralysis, anosmia, and cranial nerve injury, are discussed, as are appropriate diagnostic and radiographic testing in patients with such injuries. While conservative management is sometimes appropriate in skull base trauma, surgical access to the skull base for reconstruction of traumatic injuries may be required. A variety of specific surgical approaches to the anterior cranial fossa are discussed, including the classic anterior craniofacial approach as well as less invasive and newer endoscope-assisted approaches to the traumatized skull base.

Endoscopic Endonasal Approaches to the Cavernous Sinus: Surgical Approaches

Neurosurgery ◽  
2001 ◽  
Vol 49 (2) ◽  
pp. 354-362 ◽  
Author(s):  
Alessandra Alfieri ◽  
Hae-Dong Jho
Keyword(s):  
Cavernous Sinus ◽  
Middle Turbinate ◽  
Lateral Wall ◽  
Surgical Instruments ◽  
Surgical Approaches ◽  
Lateral Nasal Wall ◽  
Orbital Apex ◽  
Superior Orbital Fissure ◽  
Endoscopic Endonasal ◽  
Surgical Access

Abstract OBJECTIVE After completion of an earlier endoscopic transsphenoidal anatomic study, we studied various endoscopic transsphenoidal approaches using cadaveric specimens to develop endoscopic endonasal surgical approaches to the cavernous sinus. METHODS Ten cavernous sinuses in five artery-injected adult cadaveric heads were studied with 0-, 30-, and 70-degree angled 4-mm rod-lens endoscopes. The extent of the surgical exposure, the skewed endoscopic anatomic view, and the maneuverability of surgical instruments through their relative operating spaces were studied after various endoscopic endonasal approaches via one nostril. RESULTS The paraseptal approach was used between the nasal septum and the middle turbinate and provided exposure at the anteromedial portion of the cavernous sinus. The contralateral paraseptal approach rendered a slightly more medial view at the cavernous sinus than did the ipsilateral approach. This approach offered limited surgical access to the lateral vertical compartment. The middle turbinectomy approach allowed surgical access to the lateral wall of the cavernous sinus, except for the superior orbital fissure and the orbital apex. The middle meatal approach, which was made between the middle turbinate and the lateral nasal wall, revealed the entire lateral vertical compartment of the cavernous sinus, including the orbital apex and the superior orbital fissure. However, its lateral tangential surgical trajectory and the absence of dedicated surgical tools limited the surgeon's surgical maneuverability. A combination of the middle turbinectomy and middle meatal approaches increased the operating space. CONCLUSION Various endoscopic endonasal surgical approaches to the cavernous sinus were studied using adult cadaveric head specimens.

Microsurgical Resection of a Petroclival Epidermoid Cyst Using an Anterior Petrosectomy Approach: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Kunal V Vakharia ◽  
Ryan M Naylor ◽  
Ashley M Nassiri ◽  
Colin L W Driscoll ◽  
Michael J Link
Keyword(s):  
Epidermoid Cyst ◽  
Cranial Nerves ◽  
Residual Tumor ◽  
Middle Meningeal Artery ◽  
Neural Tube Closure ◽  
Petrous Apex ◽  
Meckel’S Cave ◽  
Postoperative Mri ◽  
Meckel's Cave ◽  
Anterior Petrosectomy

Abstract Epidermoid cysts are rare, benign lesions that result from inclusion of ectodermal elements during neural tube closure.1 Cysts are composed of desquamated epithelial cells and restrict diffusion on magnetic resonance imaging (MRI).2,3 Symptoms are attributable to anatomic location.4,5 In this video, we illustrate the surgical treatment of an epidermoid cyst located in the right cerebellopontine angle, petrous apex, and Meckel's cave. The patient, a 33-yr-old female with right-sided V1 trigeminal hypoesthesia, underwent surveillance imaging for 2 yr. However, she developed progressive V1 and V2 trigeminal hypoesthesia and imaging revealed enlargement of the lesion. Therefore, surgical resection was pursued. The patient consented to the procedure. The patient underwent a right middle fossa craniotomy and anterior petrosectomy. After identifying the greater superficial petrosal nerve and cutting the middle meningeal artery as it exited foramen spinosum, Kawase's triangle was drilled, and the dura over Meckel's cave and the subtemporal dura were opened. The lesion was resected, taking care to preserve the trigeminal nerve and the basilar artery. A retrosigmoid craniotomy was then fashioned. The cyst and its capsule were dissected off the brainstem and cranial nerves utilizing natural corridors between the trigeminal and vestibulocochlear nerves as well as between the facial and lower cranial nerves. Gross total resection was confirmed on postoperative MRI, and she was discharged home on postoperative day 5. Three months after surgery, she underwent formal pinprick testing, which revealed 95% loss of sensation in V1, 20% loss in V2, and normal sensation in V3. Three-month postoperative MRI showed no residual tumor.

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