scholarly journals Combined Microscopic-Endoscopic Transmastoid Resection of a Petrous Meningioma: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Walid Ibn Essayed ◽  
Emad Aboud ◽  
Ossama Al-Mefty
Keyword(s):  
Cranial Nerves ◽  
Petrous Bone ◽  
Sigmoid Sinus ◽  
Petrous Apex ◽  
Surgical Removal ◽  
Endoscopic Techniques ◽  
Petroclival Meningiomas ◽  
Close Relationship ◽  
Dural Attachment ◽  
Cerebellar Retraction

Abstract Petrous meningiomas are defined as tumors with a basal dural attachment on the posterior surface of the petrous bone.1 Their insertion can be anterior to the meatus (petrous apex meningiomas), or posterior to the meatus, with associated hyperostotic bony invasion either pre- or retro-meatal.2 These meningiomas are amenable to curative surgical removal and have better surgical outcomes than more medially located true petroclival meningiomas that originate medial to the fifth nerve.2-4 They, however, remain challenging because of their close relationship to critical neurovascular structures in the cerebellopontine angle.5 The posterior petrous meningiomas might reach a significant size with compression of the cerebellum, the brainstem, and involvement of the cranial nerves, and extend posteriorly to the transverse sigmoid sinus.2,6  Transmastoid approach with skeletonization and lateral reflection of the transverse sigmoid sinus provides a superb exposure without cerebellar retraction.6,7 The ease and complete resection of the tumor and invaded bone can be facilitated by combined microscopic-endoscopic techniques. We demonstrate these principles through the resection of a petrosal meningioma in a 56-yr-patient who presented with headaches, nystagmus, and mild cerebellar signs. The patient consented to the procedure.  Image at 1:36 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, ©LWW, 1998.

scholarly journals Two-Stage Double Petrosal Approach for the Total Resection of Petroclival-Cavernous Meningioma: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Emad Aboud ◽  
Walid Ibn Essayed ◽  
Ossama Al-Mefty
Keyword(s):  
Cavernous Sinus ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Transverse Sinus ◽  
Jugular Bulb ◽  
Neurological Deficits ◽  
Surgical Removal ◽  
Petroclival Meningiomas ◽  
Significant Extension ◽  
Anterior Petrosectomy

Abstract The utilization of skull base approaches has markedly facilitated the safe surgical removal of challenging petroclival meningiomas.1 The anterior petrosal approach has been utilized for tumors limited to the upper clivus, above the meatus, whereas the posterior petrosal approach has been the workhorse for the resection of larger tumors in the posterior fossa extending down the clivus.2 Giant cases with extension in the middle fossa, cavernous sinus, and ventral to the brain stem would benefit from a wider exposure than each of these approaches provide. This could be achieved by total petrosectomy. However, in patients with serviceable hearing anterior and posterior petrosals can be combined while preserving the hearing apparatus.2,3 This procedure is lengthy; hence, we tend to stage it in 2 subsequent days. The first stage is focused on the soft tissue and bone work including the mastoidectomy, sigmoid transverse sinus, and jugular bulb skeletonization, as well as anterior petrosectomy. The second stage is dedicated to tumor exposure through tentorial sectioning and microsurgical resection. We report the case of a 40-yr-old woman diagnosed with large left-sided petroclival meningioma with significant extension into the cavernous sinus and Meckel's cave. The patient had neurological deficits including cranial nerves, cerebellar dysfunction, and hydrocephalus, although her hearing was intact. Total tumor resection was achieved through the double petrosal approach in 2002. Extensive anatomic knowledge and thorough preoperative clinical and radiological evaluation, particularly the venous system, are key in the successful planning of this procedure. The patient consented for surgery and publication of their image.  Figures at 2:40 and 3:47, ©Ossama Al-Mefty, used with permission.

The Supra/Infra Transtentorial Transfalcine Approach for the Removal of a Falcotentorial Meningioma: 2-Dimensional Video

2018 ◽  
Vol 16 (6) ◽  
pp. E166-E167
Author(s):  
Diego Mendez-Rosito
Keyword(s):  
External Ventricular Drainage ◽  
Pineal Region ◽  
Surgical Approaches ◽  
Surgical Removal ◽  
Falx Cerebri ◽  
Sagittal Sinus ◽  
Adjacent Structures ◽  
Close Relationship ◽  
Dural Attachment ◽  
Neurologically Intact

Abstract Falcotentorial meningiomas originate in the junction of the falx cerebri and the tentorium. Due to its anatomic vicinity, these tumors have a close relationship with important neurovascular structures surrounding the pineal region including the deep venous system. Surgical approaches would normally consider posterior midline corridors, but decision between supra or infratentorial access should be considered by the size, anatomic displacement of structures, and the infiltration of the dural attachment. This surgical video1,2 demonstrates the surgical technique and pearls to achieve a stepwise resection of a complex falcotentorial meningioma. We present a case of a 42-yr-old female patient, neurologically intact at presentation. A semi-sitting position was used. Appropriate management of cerebrospinal fluid was obtained with an external ventricular drainage which is kept closed until the dura is opened. A suprainfratentorial craniotomy was done with adequate exposure of the superior sagittal sinus and torcula. The supracerebellar infratentorial corridor was used for inferior internal debulking and arachnoidal dissection of the tumor while the exposure obtained in the posterior interhemispheric allowed a corridor which exposed widely the tumor with transtentorial transfalcine extension. Adequate management of adjacent structures was done while preserving the straight sinus and vein of Galen. A gross total removal of the tumor was achieved and the patient was discharged without complications. After this surgical video, the viewer will have learned the steps to safely achieve a surgical removal of a falcotentorial meningioma taking care of its relationship with the venous and neural adjacent structures.

Surgical removal of giant acoustic neurinomas involving the skull base

1989 ◽  
Vol 71 (4) ◽  
pp. 611-615 ◽  
Author(s):  
Yutaka Sawamura ◽  
Yoku Nakagawa ◽  
Toshio Ikota ◽  
Hiroshi Abe
Keyword(s):  
Skull Base ◽  
Temporal Bone ◽  
Infratemporal Fossa ◽  
Cranial Nerves ◽  
Internal Auditory Canal ◽  
Petrous Bone ◽  
Neurological Deficits ◽  
Surgical Removal ◽  
Sphenoidal Sinus ◽  
Content Type

✓ Neurinomas arising from the peripheral branch of the acoustic nerve distal to the internal auditory canal in the temporal bone are rare. Two advanced skull-base neurinomas are described which were situated mainly in the temporal petrous bone, and extended to the parapharyngeal space anteriorly, to the lateral cervical portion inferiorly, into the sphenoidal sinus medially, and into the middle and posterior cranial fossae compressing the brain stem. Both patients had been deaf for several years without other neurological deficits. The operative findings revealed that the fifth, seventh, and caudal cranial nerves were intact; therefore, it was suspected that these neurinomas originated primarily within the cochlea or the vestibule in the temporal bone. The tumors were completely removed via an extradural approach, with good results. Since the surgical treatment of such advanced skull-base neurinomas is difficult, the operative infratemporal fossa approach is described in detail.

Decision making for the surgical approach of posterior petrous bone meningiomas

2011 ◽  
Vol 30 (5) ◽  
pp. E14 ◽  
Author(s):  
Pierre-Hugues Roche ◽  
Vincent Lubrano ◽  
Rémy Noudel ◽  
Anthony Melot ◽  
Jean Régis
Keyword(s):  
Cranial Nerves ◽  
Internal Auditory Canal ◽  
Case Series ◽  
Postoperative Mortality ◽  
Type A ◽  
Petrous Bone ◽  
Retrosigmoid Approach ◽  
Tumor Diameter ◽  
Dural Attachment ◽  
Anterior Petrosectomy

Object The authors undertook this study to examine the surgical approaches used to treat posterior petrous bone meningiomas at a single institution and retrospectively evaluate their surgical strategy based on a previously published classification. Methods Cases in which craniotomies were performed to treat posterior petrous bone meningiomas between 2002 and 2010 were retrospectively reviewed. Data were examined from 57 patients who were treated for 59 tumors. The tumors were classified into 3 types according to the location of their primary dural attachment: Type A, located around the porus trigeminus (33 tumors); Type M, located at the level of the porus of the internal auditory canal (IAC) (12 tumors); and Type P, located laterally to the IAC (14 tumors). The median tumor diameter was 34 mm (range 20–67 mm). Results The choice of the approach was based on tumor location, as the displacement of vascular structures and cranial nerves was primarily determined by the site of dural attachment on the posterior petrous bone. An anterior petrosectomy was performed in 82% of Type A meningiomas, and a retrosigmoid approach was used in 86% of Type P meningiomas. The spectrum of approaches was less uniform for Type M meningiomas. Overall, total resection was obtained in 39% of all cases, and in 18%, 50%, and 86% of Type A, Type M, and Type P tumors, respectively. The postoperative mortality rate was 8.8% (5 deaths among 57 patients), and all 5 patients who died during the early postoperative period had large Type A tumors. At last follow-up, the functional preservation of the facial nerve was excellent in 49 (94%) of the 52 surviving patients. Conclusions The authors believe that proper selection of the approach favorably impacts functional outcome in patients undergoing surgery for the treatment of skull base tumors. In the authors' case series of posterior petrous bone meningiomas, Type P and most Type M tumors were safely managed through a regular retrosigmoid approach, whereas Type A tumors were optimally treated via an epidural anterior petrosectomy.

Zygomatic Approach to Cavernous Sinus Chordoma: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Antonio Aversa ◽  
Ossama Al-Mefty
Keyword(s):  
Carotid Artery ◽  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Cranial Nerves ◽  
Radical Resection ◽  
High Rate ◽  
Petrous Apex ◽  
High Dose ◽  
Middle Fossa ◽  
Cavernous Carotid Artery

Abstract Chordoma is not a benign disease. It grows invasively, has a high rate of local recurrence, metastasizes, and seeds in the surgical field.1 Thus, chordoma should be treated aggressively with radical resection that includes the soft tissue mass and the involved surrounding bone that contains islands of chordoma.2–5 High-dose radiation, commonly by proton beam therapy, is administered after gross total resection for long-term control. About half of chordoma cases occupy the cavernous sinus space and resecting this extension is crucial to obtain radical resection. Fortunately, the cavernous sinus proper extension is the easier part to remove and pre-existing cranial nerves deficit has good chance of recovery. As chordomas originate and are always present extradurally (prior to invading the dura), an extradural access to chordomas is the natural way for radical resection without brain manipulation. The zygomatic approach is key to the middle fossa, cavernous sinus, petrous apex, and infratemporal fossa; it minimizes the depth of field and is highly advantageous in chordoma located mainly lateral to the cavernous carotid artery.6–12 This article demonstrates the advantages of this approach, including the mobilization of the zygomatic arch alleviating temporal lobe retraction, the peeling of the middle fossa dura for exposure of the cavernous sinus, the safe dissection of the trigeminal and oculomotor nerves, and total control of the petrous and cavernous carotid artery. Tumor extensions to the sphenoid sinus, sella, petrous apex, and clivus can be removed. The patient is a 30-yr-old who consented for surgery.

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.

Maturation of the anterior petrous apex: surgical relevance for performance of the middle fossa transpetrosal approach in pediatric patients

2021 ◽  
pp. 1-7
Author(s):  
Robert C. Rennert ◽  
Michael G. Brandel ◽  
Jeffrey A. Steinberg ◽  
David D. Gonda ◽  
Rick A. Friedman ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Internal Carotid ◽  
Age Groups ◽  
Internal Auditory Canal ◽  
Petrous Bone ◽  
Growth Patterns ◽  
Ct Scans ◽  
Petrous Apex ◽  
Middle Fossa ◽  
Region Growth

OBJECTIVE The middle fossa transpetrosal approach to the petroclival and posterior cavernous sinus regions includes removal of the anterior petrous apex (APA), an area well studied in adults but not in children. To this end, the authors performed a morphometric analysis of the APA region during pediatric maturation. METHODS Measurements of the distance from the clivus to the internal auditory canal (IAC; C-IAC), the distance of the petrous segment of the internal carotid artery (petrous carotid; PC) to the mesial petrous bone (MPB; PC-MPB), the distance of the PC to the mesial petrous apex (MPA; PC-MPA), and the IAC depth from the middle fossa floor (IAC-D) were made on thin-cut CT scans from 60 patients (distributed across ages 0–3, 4–7, 8–11, 12–15, 16–18, and > 18 years). The APA volume was calculated as a cylinder using C-IAC (length) and PC-MPB (diameter). APA pneumatization was noted. Data were analyzed by laterality, sex, and age. RESULTS APA parameters did not differ by laterality or sex. APA pneumatization was seen on 20 of 60 scans (33.3%) in patients ≥ 4 years. The majority of the APA region growth occurred by ages 8–11 years, with PC-MPA and PC-MPB increasing 15.9% (from 9.4 to 10.9 mm, p = 0.08) and 23.5% (from 8.9 to 11.0 mm, p < 0.01) between ages 0–3 and 8–11 years, and C-IAC increasing 20.7% (from 13.0 to 15.7 mm, p < 0.01) between ages 0–3 and 4–7 years. APA volume increased 79.6% from ages 0–3 to 8–11 years (from 834.3 to 1499.2 mm3, p < 0.01). None of these parameters displayed further significant growth. Finally, IAC-D increased 51.1% (from 4.3 to 6.5 mm, p < 0.01) between ages 0–3 and adult, without significant differences between successive age groups. CONCLUSIONS APA development is largely complete by the ages of 8–11 years. Knowledge of APA growth patterns may aid approach selection and APA removal in pediatric patients.

scholarly journals Hearing and Facial Function After Surgical Removal of Cholesteatomas Involving Petrous Bone

2014 ◽  
Vol 7 (4) ◽  
pp. 264 ◽  
Author(s):  
Min Joo Kim ◽  
Yun Suk An ◽  
Min Seok Jang ◽  
Yang-Sun Cho ◽  
Jong Woo Chung
Keyword(s):  
Petrous Bone ◽  
Surgical Removal ◽  
Facial Function

EFFECTS OF USING COMBINED TRANSPETROSAL SURGICAL APPROACHES TO TREAT PETROCLIVAL MENINGIOMAS

Neurosurgery ◽  
2007 ◽  
Vol 60 (6) ◽  
pp. 982-992 ◽  
Author(s):  
Tiit Mathiesen ◽  
Åsa Gerlich ◽  
Lars Kihlström ◽  
Mikael Svensson ◽  
Dan Bagger-Sjöbäck
Keyword(s):  
Facial Nerve ◽  
Psychosocial Support ◽  
Cranial Nerves ◽  
Negative Influence ◽  
Surgical Approaches ◽  
Tumor Control ◽  
Recurrence Rates ◽  
Trigeminal Neuropathy ◽  
Mean Values ◽  
Petroclival Meningiomas

Abstract OBJECTIVE Surgical treatment may be required for large petroclival meningiomas; however, surgery for these lesions is a major undertaking, and modern surgical approaches are still associated with considerable morbidity and recurrence rates. We analyzed our series of transpetrosally operated petroclival meningiomas to obtain detailed information regarding the surgery outcomes with respect to facial nerve effects, hearing changes, general neurological and psychosocial differences, and recurrence rates to identify opportunities for improvement. METHODS Between 1994 and 2004, we used transpetrosal approaches to operate on 29 patients for petroclival meningiomas larger than 30 mm. All patients were analyzed in detail regarding neurological outcomes and hearing abilities after surgery. Swedish-speaking patients were contacted for a psychosocial follow-up evaluation using the short-item 36 (SF-36) form. Results After surgery, the Glasgow Outcome Score improved in 14 patients, was unchanged in 11 patients, and worsened in four patients. Facial nerve function was found to be of House-Brackmann Grade 3 or worse in six patients (including three individuals with transcochlear surgery and facial nerve rerouting). Of the 23 patients who underwent hearing-preservation surgery, serviceable hearing was preserved in 17 individuals. Nineteen Swedish patients were contacted for psychosocial evaluation. Three patients could not participate for health reasons; of the remaining 16 patients, 12 reported physical health scores that were below mean values for the general population. For patients who did not experience very serious neurological compromise, we found that unexpected painful trigeminal neuropathy and unilateral swallowing difficulties conveyed a negative influence on health. Three years after surgery, the patients reported more normalized health scores. CONCLUSION Generally, outcomes compared well with current reports. Outcomes can be improved, however by improving patients' psychosocial support; striving to decompress, preserve, and minimize dissection of ill-defined planes of cranial nerves; and using Simpson Grade 4 gamma knife approaches when radicality is precluded. Currently, the performance of transpetrosal surgery for petroclival meningiomas is a major undertaking that significantly affects a patient's health for several years; however, the approaches that we used allowed a high degree of tumor control with relatively little neurological morbidity.

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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