Hypoglossal Nerve Schwannoma With Severe Brainstem Compression: Microsurgical Excision by Extreme Lateral Approach: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Qazi Zeeshan ◽  
Sneha Chitra Balasubramanian ◽  
Juan P Carrasco Hernandez ◽  
Varadaraya S Shenoy ◽  
Isaac Josh Abecassis ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Cranial Nerve ◽  
Cranial Nerves ◽  
Nerve Fibers ◽  
Left Vertebral Artery ◽  
Cystic Tumor ◽  
Occipital Condyle ◽  
Limb Weakness ◽  
Posterior Aspect ◽  
Hypoglossal Canal

Abstract A 37-yr-old male presented with a history of left-sided tongue atrophy and fasciculations and weakness of upper limbs for 3 mo. Magnetic resonance imaging (MRI) revealed a large, partially cystic tumor with severe compression of the brainstem and spinal cord, with expansion and erosion of the hypoglossal canal. Computed tomography (CT) angiography showed the left vertebral artery to be anteriorly displaced by the tumor.  A retrosigmoid craniotomy and craniectomy were performed followed by mastoidectomy with unroofing the posterior aspect of the sigmoid sinus. The foramen magnum was completely unroofed. The hypoglossal canal was exposed with a diamond drill and an ultrasonic bone curette, and a tumor was seen within the expanded canal. C1 lamina was removed partially in the lateral aspect, and the occipital condyle was partially removed. After opening the dura mater, the tumor was found to be stretching the eleventh cranial nerve. The tumor was debulked, and dissected from the cranial nerve fibers. The vertebral artery, anterior spinal artery, and other branches displaced by the tumor were carefully preserved. The tumor was removed from the hypoglossal canal with a curette. The patient recovered well, with the resolution of his upper limb weakness. Patient modified Rankin Scale was 1 at 6-mo follow-up. The postoperative MRI showed a small remnant inside the hypoglossal canal, and it was treated by radiosurgery.  This 2-dimensional video demonstrates the technique of complete microsurgical removal of a complex tumor with preservation of cranial nerves and vertebral artery.  Informed consent was obtained from the patient prior to the surgery, which included videotaping of the procedure and its distribution for educational purposes. Also, all relevant patient identifiers have been removed from the video and accompanying radiology slides.

scholarly journals Resection of a Lower Clival Meningioma via Posterolateral Approach: Two-Dimensional Operative Video

2020 ◽  
Author(s):  
Pinar E. Ocak ◽  
Selcuk Yilmazlar
Keyword(s):  
Cranial Nerve ◽  
Cranial Nerves ◽  
Posterolateral Approach ◽  
Left Vertebral Artery ◽  
Posterior Arch ◽  
Upper Cervical Spine ◽  
Two Dimensional ◽  
Lower Cranial Nerve ◽  
Complex Anatomy ◽  
Microsurgical Resection

Abstract Objectives This study aimed to demonstrate resection of a craniovertebral junction (CVJ) meningioma via the posterolateral approach. Design The study is designed with a two-dimensional operative video. Setting This study is conducted at department of neurosurgery in a university hospital. Participants A 50-year-old woman who presented with lower cranial nerve findings due to a left-sided lower clival meningioma (Fig. 1). Main Outcome Measures Microsurgical resection of the meningioma and preservation of the neurovascular structures. Results The patient was placed in park-bench position and a left-sided retrosigmoid suboccipital craniotomy, followed by C1 hemilaminectomy and unroofing the lip of the foramen magnum, was performed. The dural incision extended from the suboccipital region down to the posterior arch of C2 (Fig. 2). The arachnoid overlying the tumor was incised, revealing the course of the cranial nerve (CN) XI on the dorsolateral aspect of the tumor. The left vertebral artery (VA) was encased by the tumor which was originating from the dura below the jugular foramen. The mass was resected in a piecemeal fashion eventually. At the end of the procedure, all relevant cranial nerves and adjacent vascular structures were intact. Postoperative magnetic resonance imaging (MRI) confirmed total resection and the patient was discharged home on postoperative day 3 safely. Conclusions Microsurgical resection of the lesions of the CVJ are challenging as this transition zone between the cranium and upper cervical spine has a complex anatomy. Since adequate exposure of the extradural and intradural segments of the VA can be obtained by the posterolateral approach, this approach can be preferred in cases with tumors anterior to the VA or when the artery is encased by the tumor.The link to the video can be found at: https://youtu.be/d3u5Qrc-zlM.

Bow Hunter's Syndrome: Complete Microsurgical Decompression of Vertebral Artery by Far Lateral Retrocondylar Approach: 3-Dimensional Operative Video

2019 ◽  
Author(s):  
Qazi Zeeshan ◽  
Juan P Carrasco Hernandez ◽  
Laligam N Sekhar
Keyword(s):  
Vertebral Artery ◽  
Nerve Root ◽  
Dynamic Compression ◽  
Skin Incision ◽  
Left Vertebral Artery ◽  
Occipital Condyle ◽  
Cerebral Angiogram ◽  
Microsurgical Decompression ◽  
C2 Nerve Root ◽  
The Right

Abstract This 50-yr-old man had a 15-yr history of presyncopal episodes that were precipitated by turning his head to the right, and had worsened recently. Cerebral angiogram demonstrated complete cessation of anterograde flow in left vertebral artery (VA) at the level of the C1 sulcus arteriosus while turning head to right, indicating dynamic compression at the C1 level.  Patient underwent left extreme lateral retrocondylar approach, partial C1 laminectomy and opening of the C1 foramen with complete microsurgical decompression of the VA. After skin incision, meticulous muscle dissection was performed and superior and inferior oblique muscles were disconnected from the tubercle of C1. The VA was exposed, and three areas of constriction were visible, first at the atlanto-occipital membrane laterally; second, located more medially as the artery curved around the occipital condyle to enter the posterior fossa; and third, located anterior to C2 nerve root. The artery was dissected from all the surrounding tissues, preserving the C2 nerve root, and the Cl foramen was opened completely. The Cl lamina was also partially resected and grooved to allow free placement of the VA. The VA was also decompressed near the C2 foramen. Postoperative computed tomography angiogram of the head and neck showed complete decompression of VA. The patient had no episodes of presyncope or dizziness while turning head to right and his mRs was 0 at 8 mo follow up.  This 3D video shows the technical nuances of decompression of V3 segment of VA in bow hunters's syndrome.  Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

Partial Transcondylar Approach for Ventral Foramen Magnum Neurenteric Cyst: 2-Dimensional Operative Video

2018 ◽  
Vol 16 (3) ◽  
pp. E81-E81
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno ◽  
Hitoshi Izawa ◽  
Yujiro Tanaka
Keyword(s):  
Cranial Nerves ◽  
Three Dimensional ◽  
Posterior Part ◽  
Foramen Magnum ◽  
Neurological Deficits ◽  
Cystic Tumor ◽  
Occipital Condyle ◽  
Neurenteric Cyst ◽  
Posterior Arch ◽  
Transcondylar Approach

Abstract The anterior foramen magnum area, ventral to the brainstem is one of the most difficult regions to access surgically, and the extent of osseous drilling through the far-lateral or transcondylar approach should be planned in each case based on the tumor extension.1,2 This video, reproduced after informed consent of the patient, demonstrates a case of a ventral foramen magnum neurenteric cyst surgically treated using the partial transcondylar approach. A 27-yr-old woman presented with gait disturbance, oscillopsia, and transient arm numbness. Neuroimaging revealed a ventral foramen magnum cystic tumor involving the basilar and bilateral vertebral arteries. The tumor extended inferiorly from the middle clivus to the C1 level, and occupied the whole premedullary cistern compressing the bilateral lower cranial nerves. The left partial transcondylar approach was performed with drilling the condylar fossa, superior part of the occipital condyle, C1 posterior arch, and posterior part of the jugular process to achieve the sufficient surgical view from the inferolateral side. The drilling of the occipital condyle was minimized so that the articular facet of the occipital condyle was preserved. The tumor on the bilateral side was completely removed as enabled by the sufficient surgical field without new neurological deficits. Three-dimensional reconstructed images based on the postoperative computed tomography scans demonstrated the appropriate extent of the osseous drilling.

scholarly journals Chronic inflammatory demyelinating polyneuropathy with hypoglossal nerve involvement and inverted Beevor’s sign: case report

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Huajian Zhao ◽  
Yiming Zheng ◽  
Lingchao Meng ◽  
Meng Yu ◽  
Wei Zhang ◽  
...  
Keyword(s):  
Cranial Nerve ◽  
Hypoglossal Nerve ◽  
Chronic Inflammatory Demyelinating Polyneuropathy ◽  
Cranial Nerves ◽  
Sensory Impairment ◽  
Cranial Nerve Involvement ◽  
Limb Weakness ◽  
Glucocorticoid Treatment ◽  
Case Presentation ◽  
Nerve Involvement

Abstract Background Cranial nerve involvement is not commonly encountered in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP); this is especially true for involvement of the hypoglossal nerve. Neither Beevor's sign nor its inverted form has previously been described in CIDP. Case presentation A 28-year-old man presented with distal-predominant limb weakness and numbness at the age of 18. A diagnosis of CIDP was made, which was confirmed by electrodiagnostic evidence of demyelination. He responded well to intravenous immunoglobulin and glucocorticoid treatment and achieved remission for 5 years. However, the same symptoms relapsed at the age of 28 and lasted for 10 months. On examination, in addition to limb sensory impairment and muscle weakness, mild bilateral facial paresis, tongue atrophy and fasciculations, and inverted Beevor's sign were also observed. A brief literature review of cranial nerve involvements in CIDP and Beevor's sign or its inverted form were also performed. Conclusions Cranial nerves may be affected in patients with CIDP. Facial palsy is most frequently present, while hypoglossal nerve involvement is rare. Inverted Beevor's sign can appear in CIDP patients.

“Far-Medial” Expanded Endonasal Approach to the Inferior Third of the Clivus

2010 ◽  
Vol 66 (suppl_2) ◽  
pp. ons211-ons220 ◽  
Author(s):  
Victor A. Morera ◽  
Juan C. Fernandez-Miranda ◽  
Daniel M. Prevedello ◽  
Ricky Madhok ◽  
Juan Barges-Coll ◽  
...  
Keyword(s):  
Cranial Nerves ◽  
Foramen Magnum ◽  
Direct Access ◽  
Occipital Condyle ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Hypoglossal Canal ◽  
Expanded Endonasal Approach ◽  
Surgical Corridor ◽  
Lower Cranial Nerves

Abstract OBJECTIVE The endoscopic endonasal transclival approach is a valid alternative for treatment of lesions in the clivus. The major limitation of this approach is a significant lateral extension of the tumor. We aim to identify a safe corridor through the occipital condyle to provide more lateral exposure of the foramen magnum. METHODS Sixteen parameters were measured in 25 adult skulls to analyze the exact extension of a safe corridor through the condyle. Endonasal endoscopic anatomic dissections were carried out in nine colored latex–injected heads. RESULTS Drilling at the lateral inferior clival area exposed two compartments divided by the hypoglossal canal: the jugular tubercle (superior) and the condylar (inferior). Completion of a unilateral ventromedial condyle resection opens a 3.5 mm (transverse length) * 10 mm (vertical length) lateral surgical corridor, facilitating direct access to the vertebral artery at its dural entry point into the posterior fossa. The supracondylar groove is a reliable landmark for locating the hypoglossal canal in relation to the condyle. The hypoglossal canal is used as the posterior limit of the condyle removal to preserve more than half of the condylar mass. The transjugular tubercle approach is accomplished by drilling above the hypoglossal canal, and increases the vertical length of the lateral surgical corridor by 8 mm, allowing for visualization of the distal cisternal segment of the lower cranial nerves. CONCLUSION The transcondylar and transjugular tubercle “far medial” expansions of the endoscopic endonasal approach to the inferior third of the clivus provide a unique surgical corridor to the ventrolateral surface of the ponto- and cervicomedullary junctions.

scholarly journals Hypoglossal canal schwannoma causing isolated left 12th cranial nerve palsy

2018 ◽  
pp. bcr-2018-225544 ◽  
Author(s):  
Shruti Heda ◽  
Davala Krishna Karthik ◽  
Erigaisi Srinivas Rao ◽  
Anirudda Deshpande
Keyword(s):  
Clinical Features ◽  
Cranial Nerve ◽  
Cranial Nerve Palsy ◽  
Nerve Palsy ◽  
Cranial Nerves ◽  
Left Half ◽  
Hypoglossal Canal ◽  
Insidious Onset ◽  
12Th Cranial Nerve ◽  
The Brain

A 40-year-old woman presented with insidious onset, gradually progressive dysarthria and inability to manoeuvre bolus of food in her mouth while eating. The duration of her symptoms was 3 months. On evaluation, the left half of her tongue was wasted. The tongue deviated to the left on protrusion. There were no clinical features suggestive of involvement of the ipsilateral 9th, 10th or 11th cranial nerves. MRI of the brain showed a large, fusiform lesion in the left hypoglossal canal, extending into the jugular canal. The lesion was surgically excised and found to be a schwannoma.

scholarly journals Foramen Magnum Meningioma: Far Lateral Approach

2019 ◽  
Vol 80 (S 04) ◽  
pp. S363-S364
Author(s):  
Ciro Vasquez ◽  
Alexander Yang ◽  
A. Samy Youssef
Keyword(s):  
Vertebral Artery ◽  
Cranial Nerves ◽  
Mass Effect ◽  
Craniocervical Junction ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Neurological Deficits ◽  
Occipital Condyle ◽  
Far Lateral Approach ◽  
Far Lateral

We present a case of a foramen magnum meningioma in a 42-year-old female who presented with headaches for 2 years, associated with decreased sensation and overall feeling of “heaviness” of the right arm. The tumor posed significant mass effect on the brainstem, and given the location of the tumor in the anterolateral region of the foramen magnum, a right far lateral approach was chosen. The approach incorporates the interfascial dissection technique to safely expose and preserve the vertebral artery in the suboccipital triangle. After drilling the posteromedial portion of the occipital condyle and opening the dura, the tumor can be entirely exposed with minimal retraction on the cerebellum. The working space offered by the far lateral approach allows careful dissection at the lateral craniocervical junction, and preservation of the V4 segment of the vertebral artery and the lower cranial nerves. Simpson's grade-2 resection was achieved with coagulation of the dural base around the vertebral artery. The postoperative course was unremarkable for any neurological deficits. At the 2-year follow-up, imaging identified no recurrence of tumor and the patient remains asymptomatic.The link to the video can be found at: https://youtu.be/IMN1O7vO5B0.

scholarly journals Resolution of intractable retching following mobilization of a dolichoectatic vertebral artery: case report of a unique brainstem–cranial nerve compression syndrome

2017 ◽  
Vol 127 (4) ◽  
pp. 761-767
Author(s):  
Scott Seaman ◽  
Paul Nelson ◽  
Jacob Alexander ◽  
Andrew Swift ◽  
James Fick
Keyword(s):  
Vertebral Artery ◽  
Cranial Nerve ◽  
Anatomical Variation ◽  
Cranial Nerves ◽  
Clinical Consequence ◽  
Vagus Nerves ◽  
Nerve Compression Syndrome ◽  
Root Entry Zone ◽  
Cranial Nerve Dysfunction ◽  
Mri Study

The authors present the case of a 53-year-old man who was referred with disabling retching provoked by left arm abduction. At the time of his initial evaluation, a cervical MRI study was available for review and revealed an anatomical variation of the ipsilateral juxtamedullary vertebrobasilar junction. After brain imaging revealed contact of the medulla by a dolichoectatic vertebral artery at the dorsal root entry zone of the glossopharyngeal and vagus nerves, the patient was successfully treated by microvascular decompression of the brainstem and cranial nerves. This case demonstrates how a dolichoectatic vertebral artery—a common anatomical variation that typically has no clinical consequence—should be considered in cases of cranial nerve dysfunction.

scholarly journals Far Lateral Transcondylar Transtubercular Approach for Microsurgical Resection of Foramen Magnum Meningioma: Operative Video and Technical Nuances

2020 ◽  
Author(s):  
James K. Liu ◽  
Vincent N. Dodson ◽  
Ali T. Meybodi
Keyword(s):  
Vertebral Artery ◽  
Cranial Nerve ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Neurological Deficits ◽  
Endoscopic Endonasal ◽  
Surgical Access ◽  
Far Lateral Approach ◽  
Far Lateral

AbstractSurgical access to the ventral foramen magnum remains a technical challenge. With large lesions in this region compressing the brainstem and distorting the regional neurovascular relationships, formulating a surgical plan and its appropriate execution have crucial importance in achieving favorable outcomes. While the endoscopic endonasal approaches have gained increasing attention to access the clivus and the ventral brainstem, foramen magnum meningiomas are still preferred to be removed via an approach that obviates a trajectory through the nasopharyngeal mucosa. Therefore, the far lateral approach remains one of the most practical approaches for these challenging lesions. This operative video demonstrates the use of the far lateral transcondylar transtubercular approach to remove a large meningioma in the ventral foramen magnum in a 63-year-old male with progressive cervical myelopathy, presenting as spastic quadriparesis without any cranial nerve abnormality. Using a right-sided far lateral transcondylar transtubercular approach, the meningioma was exposed within the cerebellomedullary gutter engulfing the vertebral artery and distorting the course of the adjacent cranial nerves. Using the different corridors identified between the vertebral artery, spinal accessory, vagus, and hypoglossal nerves, multiple angles of attacks to the tumor were established and utilized to resect the lesion. A gross total resection was achieved and the patient was neurologically intact without any neurological deficits. This video demonstrates the importance of understanding the intricacies of neurovascular anatomy of the cervicomedullary region (i.e., the various triangles formed between these structures), and the effective use of these corridors to safely and efficiently remove a challenging ventral foramen magnum meningioma with neurovascular involvement, while preserving cranial nerve function. The surgical technique and nuances are described in a step-by-step fashion in this illustrative operative video.The link to the video can be found at: https://youtu.be/s1dFhuaRSt8.

scholarly journals Lessons from the Diagnosis and Treatment of Spontaneous Vertebral Arterial Dissection

2009 ◽  
Vol 15 (2) ◽  
pp. 203-208 ◽  
Author(s):  
S. Shi ◽  
K. Chen ◽  
X. Ge ◽  
B. Ni
Keyword(s):  
Vertebral Artery ◽  
Digital Subtraction Angiography ◽  
Posterior Inferior Cerebellar Artery ◽  
Left Vertebral Artery ◽  
Digital Subtraction ◽  
Limb Weakness ◽  
Cerebellar Artery ◽  
Autopsy Data ◽  
Basilar Arteries ◽  
Occipital Headache

A 36-year-old man presented a sudden left occipital headache and right limb weakness after tooth-brushing. Conventional catheter digital subtraction angiography (DSA) showed a left VA occlusion at the crotch of the posterior inferior cerebellar artery. Four days later, the patient got worse. The angiogram showed the left vertebral artery had reopened and the basilar trunk occluded above the AICA. He died two days later and autopsy demonstrated a dissection of the basilar arteries. Based on the autopsy data from the patient in this study, we suggest that the BA dissection might be due to left VA dissection, and placing a stent on the juncture between the uninjured VA and the basilar trunk might be an effective method to prevent fatal BA occlusion.

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