A Method for Cranial Nerve XI Silencing During Surgery of the Foramen Magnum Region: Technical Case Report

2018 ◽  
Vol 16 (4) ◽  
pp. E130-E133
Author(s):  
Derek G Southwell ◽  
Jonathan D Breshears ◽  
William R Lyon ◽  
Michael W McDermott
Keyword(s):  
Skull Base ◽  
Cranial Nerve ◽  
Clinical Presentation ◽  
Obstructive Hydrocephalus ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Cerebellar Tonsil ◽  
Suboccipital Craniotomy ◽  
Far Lateral ◽  
The Right

Abstract BACKGROUND AND IMPORTANCE Skull base surgery involves the microdissection and intraoperative monitoring of cranial nerves, including cranial nerve XI (CN XI). Manipulation of CN XI can evoke brisk trapezius contraction, which in turn may disturb the surgical procedure and risk patient safety. Here we describe a method for temporarily silencing CN XI via direct intraoperative application of 1% lidocaine. CLINICAL PRESENTATION A 41-yr-old woman presented with symptoms of elevated intracranial pressure and obstructive hydrocephalus secondary to a hemangioblastoma of the right cerebellar tonsil. A far-lateral suboccipital craniotomy was performed for resection of the lesion. During the initial stages of microdissection, vigorous trapezius contraction compromised the course of the operation. Following exposure of the cranial and cervical portions of CN XI, lidocaine was applied to the course of the exposed nerve. Within 3 min, trapezius electromyography demonstrated neuromuscular silencing, and further manipulation of CN XI did not cause shoulder movements. Approximately 30 min after lidocaine application, trapezius contractions returned, and lidocaine was again applied to re-silence CN XI. Gross total resection of the hemangioblastoma was performed during periods of CN XI inactivation, when trapezius contractions were absent. CONCLUSION Direct application of lidocaine to CN XI temporarily silenced neuromuscular activity and prevented unwanted trapezius contraction during skull base microsurgery. This method improved operative safety and efficiency by significantly reducing patient movement due to the unavoidable manipulation of CN XI.

Isolated Congenital Absence of Cranial Nerves: Report of Two Cases

2018 ◽  
Vol 49 (06) ◽  
pp. 405-407
Author(s):  
Vivek Agarwal ◽  
Sumeet Dhawan ◽  
Naveen Sankhyan ◽  
Sameer Vyas
Keyword(s):  
High Resolution ◽  
Mr Imaging ◽  
Cranial Nerve ◽  
Clinical Presentation ◽  
Cranial Nerves ◽  
Rare Condition ◽  
Congenital Absence ◽  
The Third ◽  
Seventh Cranial Nerve ◽  
The Right

AbstractIsolated cranial nerve absence is a rare condition that can be diagnosed using high-resolution cranial nerve magnetic resonance (MR) imaging. Thorough clinical examination with proper knowledge of the course of cranial nerves may help diagnose this rare condition. We describe two cases, one each of, isolated congenital absence of the third and seventh cranial nerve with their clinical presentation. High-resolution T2-weighted MR imaging was done in both patients which revealed absence of cisternal segment of the right-sided third nerve and cisternal with canalicular segment of the right-sided facial nerve.

High Anterior Cervical Approach to the Clivus and Foramen Magnum: A Microsurgical Anatomy Study

2011 ◽  
Vol 69 (suppl_1) ◽  
pp. ons103-ons116 ◽  
Author(s):  
Vittorio M. Russo ◽  
Francesca Graziano ◽  
Antonino Russo ◽  
Erminia Albanese ◽  
Arthur J. Ulm
Keyword(s):  
Skull Base ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Microsurgical Anatomy ◽  
Lateral Skull Base ◽  
Cervical Approach ◽  
Anterior Cervical Approach ◽  
Vertebrobasilar Junction ◽  
Far Lateral ◽  
Lower Clivus

Abstract BACKGROUND: Surgical exposure of lesions located along the ventral foramen magnum (FM) and clivus poses a unique set of challenges to neurosurgeons. Several approaches have been developed to access these regions with varying degrees of exposure and approach-related morbidity. OBJECTIVE: To describe the microsurgical anatomy of the high anterior cervical approach to the clivus and foramen magnum, and describe novel skull base extensions of the approach. METHODS: Eight adult cadaveric specimens were included in this study. The high anterior cervical approach includes a minimal anterior clivectomy and its lateral skull base extensions: the extended anterior far-lateral clivectomy and the inferior petrosectomy. The microsurgical anatomy and exposure of the various extensions of the approach were analyzed. In addition, the capability of complementary endoscopy was evaluated. RESULTS: With proper positioning, the minimal anterior clivectomy exposed the vertebrobasilar junction, proximal basilar artery, anteroinferior cerebellar arteries, and 6th cranial nerve. The lateral skull base extensions provided access to the anterior FM, mid-lower clivus, and petroclival region, up to the Meckel cave, contralateral to the side of the surgical approach. CONCLUSION: The high anterior cervical approach with skull base extensions is an alternative to the classic approaches to the ventral FM and mid-lower clivus. A minimal anterior clivectomy provides access to the midline mid-lower clivus. The addition of an extended anterior far-lateral clivectomy and an inferior petrosectomy extends the exposure to the anterior FM and cerebellopontine angle lying anterior to the cranial nerves. The approach is also ideally suited for endoscopic-assisted techniques.

The far-lateral approach for foramen magnum meningiomas

2013 ◽  
Vol 35 (6) ◽  
pp. E12 ◽  
Author(s):  
Bruno C. Flores ◽  
Benjamin P. Boudreaux ◽  
Daniel R. Klinger ◽  
Bruce E. Mickey ◽  
Samuel L. Barnett
Keyword(s):  
Skull Base ◽  
Cervical Spinal Cord ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Surgical Approaches ◽  
Confined Space ◽  
Far Lateral Approach ◽  
Far Lateral

Foramen magnum meningiomas (FMMs) are slow growing, most often intradural and extramedullary tumors that pose significant challenges to the skull base neurosurgeon. The indolent clinical course of FMMs and their insidious onset of symptoms are important factors that contribute to delayed diagnosis and relative large size at the time of presentation. Symptoms are often produced by compression of surrounding structures (such as the medulla oblongata, upper cervical spinal cord, lower cranial nerves, and vertebral artery) within a critically confined space. Since the initial pathological description of a FMM in 1872, various surgical approaches have been described with the aim of achieving radical tumor resection. The surgical treatment of FMMs has evolved considerably over the last 4 decades due to the progress in microsurgical techniques and development of a multitude of skull base approaches. Posterior and posterolateral FMMs can be safely resected via a standard midline suboccipital approach. However, controversy still exits regarding the optimal management of anterior or anterolateral lesions. Independently of technical variations and the degree of bone removal, all modern surgical approaches to the lower clivus and anterior foramen magnum derive from the posterolateral (or far-lateral) craniotomy originally described by Roberto Heros and Bernard George. This paper is a review of the surgical management of FMMs, with emphasis on the far-lateral approach and its variations. Clinical presentation, imaging findings, important neuroanatomical correlations, recurrence rates, and outcomes are discussed.

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.

Histology of the vertebral artery–dural junction: relevance to posterolateral approaches to the skull base

2019 ◽  
pp. 1-6
Author(s):  
Robert C. Rennert ◽  
Martin P. Powers ◽  
Jeffrey A. Steinberg ◽  
Takanori Fukushima ◽  
John D. Day ◽  
...  
Keyword(s):  
Connective Tissue ◽  
Vertebral Artery ◽  
Skull Base ◽  
Histological Analysis ◽  
Foramen Magnum ◽  
Entry Site ◽  
Microsurgical Technique ◽  
Vessel Injury ◽  
Far Lateral ◽  
Clear Delineation

OBJECTIVEThe far-lateral and extreme-lateral infrajugular transcondylar–transtubercular exposure (ELITE) and extreme-lateral transcondylar transodontoid (ELTO) approaches provide access to lesions of the foramen magnum, inferolateral to mid-clivus, and ventral pons and medulla. A subset of pathologies in this region require manipulation of the vertebral artery (VA)–dural interface. Although a cuff of dura is commonly left on the VA to avoid vessel injury during these approaches, there are varying descriptions of the degree of VA-dural separation that is safely achievable. In this paper the authors provide a detailed histological analysis of the VA-dural junction to guide microsurgical technique for posterolateral skull base approaches.METHODSAn ELITE approach was performed on 6 preserved adult cadaveric specimens. The VA-dural entry site was resected, processed for histological analysis, and qualitatively assessed by a neuropathologist.RESULTSHistological analysis demonstrated a clear delineation between the intima and media of the VA in all specimens. No clear plane was identified between the connective tissue of the dura and the connective tissue of the VA adventitia.CONCLUSIONSThe VA forms a contiguous plane with the connective tissue of the dura at its dural entry site. When performing posterolateral skull base approaches requiring manipulation of the VA-dural interface, maintenance of a dural cuff on the VA is critical to minimize the risk of vascular injury.

scholarly journals Far Lateral Craniotomy for Resection of Foramen Magnum Meningioma

2019 ◽  
Vol 80 (S 04) ◽  
pp. S355-S357
Author(s):  
Robert T. Wicks ◽  
Xiaochun Zhao ◽  
Celene B. Mulholland ◽  
Peter Nakaji
Keyword(s):  
Cranial Nerves ◽  
Craniocervical Junction ◽  
Foramen Magnum ◽  
Occipital Condyle ◽  
Formidable Challenge ◽  
Close Proximity ◽  
Vertebrobasilar Circulation ◽  
Far Lateral ◽  
Lower Cranial Nerves ◽  
Gain Access

Abstract Objective Foramen magnum meningiomas present a formidable challenge to resection due to frequent involvement of the lower cranial nerves and vertebrobasilar circulation. The video shows the use of a far lateral craniotomy to resect a foramen magnum meningioma. Design, Setting, and Participant A 49-year-old woman presented with neck pain and was found to have a large foramen magnum meningioma (Fig. 1A, B). Drilling of the posterior occipital condyle was required to gain access to the lateral aspect of the brain stem. The amount of occipital condyle resection varies by patient and pathology. Outcome/Result Maximal total resection of the tumor was achieved (Fig. 1B, C), and the patient was discharged on postoperative day 4 with no neurologic deficits. The technique for tumor microdissection (Fig. 2) is shown in the video. Conclusion Given the close proximity of foramen magnum meningiomas to vital structures at the craniocervical junction, surgical resection with careful microdissection and preservation of the overlying dura to prevent postoperative pseudomeningocele is necessary to successfully manage this pathology in those patients who are surgical candidates.The link to the video can be found at: https://youtu.be/Mds9N1x2zE0.

scholarly journals Intratumoral Bleeding in a Vestibular Schwannoma

2017 ◽  
Vol 37 (01) ◽  
pp. 47-49
Author(s):  
Emanuelle Braga ◽  
Luiza Köhler ◽  
Marcelo de Cesaro ◽  
Tasso Barreto ◽  
Richard Giacomelli ◽  
...  
Keyword(s):  
Hearing Loss ◽  
Case Report ◽  
Cranial Nerve ◽  
Cerebellopontine Angle ◽  
Clinical Presentation ◽  
Cranial Nerves ◽  
Altered Consciousness ◽  
Progressive Hearing Loss ◽  
Asymptomatic Patients ◽  
Intratumoral Bleeding

AbstractVestibular schwannomas (VSs) account for ∼ 70% of all tumors of the cerebellopontine angle (CPA). Their clinical presentation is often insidious, with progressive hearing loss and involvement of other cranial nerves. Spontaneous hemorrhage in those tumors is very unusual, and generally presents with acute clinical features such as nausea, vomiting, headache and altered consciousness, usually with marked dysfunction of the cranial nerve involved, and with new deficits of neighboring cranial nerves. Asymptomatic patients are extremely rare. We present a case report of an incidental VS with asymptomatic bleeding, which evolved to death after surgery.

scholarly journals Technical strategies to approach aneurysms of the vertebral and posterior inferior cerebellar arteries

2005 ◽  
Vol 19 (2) ◽  
pp. 1-5 ◽  
Author(s):  
Niklaus Krayenbühl ◽  
Carlos A. Guerrero ◽  
Ali F. Krisht
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Anatomical Location ◽  
Microsurgical Anatomy ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Pica Aneurysms ◽  
Lower Cranial Nerves

Object Aneurysms of the vertebral artery (VA) and proximal posterior inferior cerebellar artery (PICA) are rare and challenging lesions, as they are located in front of the brainstem and surrounded by the lower cranial nerves. Many different approaches have been described for their treatment, and have yielded different results. With the use of different examples of lesions, the authors describe their surgical strategy in the management of VA and PICA aneurysms. Methods The far-lateral approach was used, and the potential of its different extensions according to the specific anatomical location and configuration of different types of aneurysms is emphasized. Conclusions With the present knowledge of the microsurgical anatomy in the region of the foramen magnum, the far-lateral approach can be tailored to the specific anatomical and morphological configuration of an aneurysm in this region with good surgical results.

scholarly journals Tolosa-Hunt syndrome: is it really necessary to show granuloma? - The report of eight cases

2017 ◽  
Vol 74 (3) ◽  
pp. 287-293 ◽  
Author(s):  
Ana Podgorac ◽  
Jasna Zidverc-Trajkovic ◽  
Zagorka Jovanovic ◽  
Aleksandar Ristic ◽  
Aleksandra Radojicic ◽  
...  
Keyword(s):  
Diagnostic Criteria ◽  
Cranial Nerve ◽  
Clinical Presentation ◽  
Correct Diagnosis ◽  
Cranial Nerves ◽  
Granulomatous Inflammation ◽  
Diagnostic Procedures ◽  
Hunt Syndrome ◽  
Number Of Patients ◽  
Significant Difference

Introduction. Tolosa?Hunt syndrome (THS) is a rare entity, characterized by unilateral orbital pain associated with paresis of one or more of the oculomotor cranial nerves and caused by a granulomatous inflammation in the cavernous sinus, superior orbital fissure or orbit. The low prevalence of THS with a broad spectrum of other disorders that could cause painful ophtalmoplegia resulted in a stricter diagnostic criteria of THS in the latest edition of the International Classification of Headache Disorders. Current criteria require demonstration of granuloma by magnetic resonance imaging or biopsy. The diagnosis could be difficult and the initiation of treatment delayed due to a high variablity of clinical presentation of TSH. Reducing the number of patients that, based on clinical presentation, could be classified as having THS, but do not fullfil all diagnostic criteria further complicates establishing of correct diagnosis. Case report. Hereby we presented eight patients diagnosed with and treated for THS. Inspite the exclusion of other causes of painful ophtalmoplegia, granuloma could not be demonstrated in a half of patients. Clinical presentation of THS in patients with and without shown granuloma, did not significantly differ concerning headache characteristics (localization, intensity, quality, duration preceding cranial nerve palsy, response to steroids), the affected cranial nerve, disease course and response to the treatment, as well as types of diagnostic procedures that were performed in ruling out other diseases from the extensive differential diagnosis of painful ophthalmoplegia. Conclusion. There is no significant difference between the THS patients with and without demonstrated granuloma.

The Asterion-to-Transverse Process of the Atlas Line as a Surgical Landmark

2021 ◽  
Author(s):  
Jaafar Basma ◽  
Dom E. Mahoney ◽  
Christos Anagnostopoulos ◽  
L. Madison Michael ◽  
Jeffrey M. Sorenson ◽  
...  
Keyword(s):  
Skull Base ◽  
Cranial Nerves ◽  
Three Dimensional ◽  
Transverse Process ◽  
Jugular Foramen ◽  
Foramen Magnum ◽  
Sigmoid Sinus ◽  
Cervical Region ◽  
Surgical Approaches ◽  
Anatomical Location

Abstract Introduction Proposed landmarks to predict the anatomical location and trajectory of the sigmoid sinus have varying degrees of reliability. Even with neuronavigation technology, landmarks are crucial in planning and performing complex approaches to the posterolateral skull base. By combining two major dependable structures—the asterion (A) and transverse process of the atlas (TPC1)—we investigate the A-TPC1 line in relation to the sigmoid sinus and in partitioning surgical approaches to the region. Methods We dissected six cadaveric heads (12 sides) to expose the posterolateral skull base, including the mastoid and suboccipital bone, TPC1 and suboccipital triangle, distal jugular vein and internal carotid artery, and lower cranial nerves in the distal cervical region. We inspected the A-TPC1 line before and after drilling the mastoid and occipital bones and studied the relationship of the sigmoid sinus trajectory and major muscular elements related to the line. We retrospectively reviewed 31 head and neck computed tomography (CT) angiograms (62 total sides), excluding posterior fossa or cervical pathologies. Bone and vessels were reconstructed using three-dimensional segmentation software. We measured the distance between the A-TPC1 line and sigmoid sinus at different levels: posterior digastric point (DP), and maximal distances above and below the digastric notch. Results A-TPC1 length averaged 65 mm and was posterior to the sigmoid sinus in all cadaver specimens, coming closest at the level of the DP. Using the transverse-asterion line as a rostrocaudal division and skull base as a horizontal plane, we divided the major surgical approaches into four quadrants: distal cervical/extreme lateral and jugular foramen (anteroinferior), presigmoid/petrosal (anterosuperior), retrosigmoid/suboccipital (posterosuperior), and far lateral/foramen magnum regions (posteroinferior). Radiographically, the A-TPC1 line was also posterior to the sigmoid sinus in all sides and came closest to the sinus at the level of DP (mean, 7 mm posterior; range, 0–18.7 mm). The maximal distance above the DP had a mean of 10.1 mm (range, 3.6–19.5 mm) and below the DP 5.2 mm (range, 0–20.7 mm). Conclusion The A-TPC1 line is a helpful landmark reliably found posterior to the sigmoid sinus in cadaveric specimens and radiographic CT scans. It can corroborate the accuracy of neuronavigation, assist in minimizing the risk of sigmoid sinus injury, and is a useful tool in planning surgical approaches to the posterolateral skull base, both preoperatively and intraoperatively.

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