Endoscopic Endonasal Resection of Meckel’s Cave Epidermoid Cysts: Case Discussion and Literature Review

Meckel’s cave (MC) epidermoid cysts are relatively uncommon lesions. In cases where surgical excision is indicated, resection is often carried out via a frontosphenotemporal craniotomy from an anterolateral approach or a temporal craniotomy with or without a petrosectomy for a lateral corridor; both of these routes are associated with brain retraction and potential neurovascular injury. The anterior location of MC in the middle cranial fossa makes safe access via posterior fossa-based approaches—such as the retrosigmoid approach—challenging as well. Here, we present the cases of two patients diagnosed with epidermoid cysts in MC who underwent surgical resection via an endoscopic endonasal transpterygoid approach. Near-total resection was achieved in both cases, with only mild transient neurologic disturbances postoperatively. Radiographically, no evidence of residual disease was noted in either patient. We further review the nuances of an extended endoscopic endonasal approach to these lesions.

Download Full-text

Endoscopic transorbital surgery for Meckel’s cave and middle cranial fossa tumors: surgical technique and early results

Journal of Neurosurgery ◽

10.3171/2018.6.jns181099 ◽

2019 ◽

Vol 131 (4) ◽

pp. 1126-1135 ◽

Cited By ~ 9

Author(s):

Chiman Jeon ◽

Chang-Ki Hong ◽

Kyung In Woo ◽

Sang Duk Hong ◽

Do-Hyun Nam ◽

...

Keyword(s):

Surgical Techniques ◽

Middle Cranial Fossa ◽

Csf Leak ◽

Meckel’S Cave ◽

Endoscopic Endonasal ◽

Working Space ◽

Early Results ◽

Endoscopic Transorbital ◽

Meckel's Cave ◽

Cranial Fossa

OBJECTIVETumors involving Meckel’s cave remain extremely challenging because of the surrounding complex neurovascular structures and deep-seated location. The authors investigated a new minimal-access technique using the endoscopic transorbital approach (eTOA) through the superior eyelid crease to Meckel’s cave and middle cranial fossa lesions and reviewed the most useful surgical procedures and pitfalls of this approach.METHODSBetween September 2016 and January 2018, the authors performed eTOA in 9 patients with tumors involving Meckel’s cave and the middle cranial fossa. The lesions included trigeminal schwannoma in 4 patients, meningioma in 2 patients, metastatic brain tumor in 1 patient, chondrosarcoma in 1 patient, and dermoid cyst in 1 patient. In 7 of the 9 patients, eTOA alone was performed, while the other 2 patients underwent a combined eTOA and endoscopic endonasal approach or retrosigmoid craniotomy. Data including details of surgical techniques and clinical outcomes were recorded.RESULTSGross-total resection was performed in 7 of the 9 patients (77.8%). Four patients underwent extended eTOA (with lateral orbital rim osteotomy). Drilling of the trapezoid sphenoid floor, a middle fossa “peeling” technique, and full visualization of Meckel’s cave were applied to approach the lesions. Tumors were exposed and removed extradurally in 3 patients and intradurally in 6 patients. There was no postoperative CSF leak.CONCLUSIONSThe eTOA affords a direct route to access Meckel’s cave and middle cranial fossa lesions. With experience, this novel approach can be successfully applied to selected skull base lesions. To achieve successful removal of the tumor, emphasis should be placed on the importance of adequately removing the greater sphenoid wing and vertical crest. However, because of limited working space eTOA may not be an ideal approach for posterior fossa lesions.

Download Full-text

A Side Door to Meckel's Cave: Anatomic Feasibility Study for the Lateral Transorbital Approach

Operative Neurosurgery ◽

10.1093/ons/opx042 ◽

2017 ◽

Vol 13 (5) ◽

pp. 614-621 ◽

Cited By ~ 17

Author(s):

Blake Harrison Priddy ◽

Cristian Ferrareze Nunes ◽

Andre Beer-Furlan ◽

Ricardo Carrau ◽

Iacopo Dallan ◽

...

Keyword(s):

Skull Base ◽

Surgical Navigation ◽

Cranial Nerves ◽

Anatomical Study ◽

Middle Cranial Fossa ◽

Middle Fossa ◽

Meckel’S Cave ◽

Side Door ◽

Meckel's Cave ◽

Brain Retraction

Abstract BACKGROUND: In the last decade, endoscopic skull base surgery has significantly developed and generated a plethora of techniques and approaches for access to the cranial ventral floor. However, the exploration for the least-aggressive, maximally efficient approach continues. OBJECTIVE: To describe in detail an anatomical study, along with the technical nuances of a novel endoscopic approach to Meckel's Cave (MC) using a lateral transorbital (LTO) route. METHODS: Eighteen orbits of injected cadaveric specimens were operated on, using an endoscopic LTO approach to MC, middle cranial fossa, and paramedian skull base preserving the orbital rim. Surgical navigation and an after-the-fact infratemporal craniectomy were utilized to identify the limits of the approach. RESULTS: Following a transorbital approach opening a trapezoid window at the superolateral aspect (average 166.7 mm2), a middle fossa “peeling” and full visualization of MC was accomplished with no difficulties in all specimens. The entire approach was performed extradurally without the need to expose the temporal lobe. CONCLUSION: In a cadaveric model, the endoscopic LTO approach affords a direct route to access MC. Its main advantage is that it is minimally disruptive in nature, less brain retraction is required, and it reaches the middle fossa in an anterolateral perspective. It also requires no manipulation of the temporalis muscle, limited cosmetic incision, and rapid recovery. It seems a viable alternative to traditional approaches for lesions lateral to the cranial nerves at the cavernous sinus and MC, that is, schwannomas. Clinical utilization of this approach will challenge its efficacy and identify limitations.

Download Full-text

Endoscopic anterior transmaxillary “transalisphenoid” approach to Meckel’s cave and the middle cranial fossa: an anatomical study and clinical application

Journal of Neurosurgery ◽

10.3171/2017.8.jns171308 ◽

2018 ◽

Vol 130 (1) ◽

pp. 227-237 ◽

Cited By ~ 9

Author(s):

Huy Q. Truong ◽

Xicai Sun ◽

Emrah Celtikci ◽

Hamid Borghei-Razavi ◽

Eric W. Wang ◽

...

Keyword(s):

Maxillary Sinus ◽

Cavernous Sinus ◽

Infratemporal Fossa ◽

Middle Cranial Fossa ◽

Anatomical Landmarks ◽

Middle Fossa ◽

Meckel’S Cave ◽

Meckel's Cave ◽

Cranial Fossa ◽

Greater Wing

OBJECTIVEMultiple approaches have been designed to reach the medial middle fossa (for lesions in Meckel’s cave, in particular), but an anterior approach through the greater wing of the sphenoid (transalisphenoid) has not been explored. In this study, the authors sought to assess the feasibility of and define the anatomical landmarks for an endoscopic anterior transmaxillary transalisphenoid (EATT) approach to Meckel’s cave and the middle cranial fossa.METHODSEndoscopic dissection was performed on 5 cadaver heads injected intravascularly with colored silicone bilaterally to develop the approach and define surgical landmarks. The authors then used this approach in 2 patients with tumors that involved Meckel’s cave and provide their illustrative clinical case reports.RESULTSThe EATT approach is divided into the following 4 stages: 1) entry into the maxillary sinus, 2) exposure of the greater wing of the sphenoid, 3) exposure of the medial middle fossa, and 4) exposure of Meckel’s cave and lateral wall of the cavernous sinus. The approach provided excellent surgical access to the anterior and lateral portions of Meckel’s cave and offered the possibility of expanding into the infratemporal fossa and lateral middle fossa and, in combination with an endonasal transpterygoid approach, accessing the anteromedial aspect of Meckel’s cave.CONCLUSIONSThe EATT approach to Meckel’s cave and the middle cranial fossa is technically feasible and confers certain advantages in specific clinical situations. The approach might complement current surgical approaches for lesions of Meckel’s cave and could be ideal for lesions that are lateral to the trigeminal ganglion in Meckel’s cave or extend from the maxillary sinus, infratemporal fossa, or pterygopalatine fossa into the middle cranial fossa, Meckel’s cave, and cavernous sinus, such as schwannomas, meningiomas, and sinonasal tumors and perineural spread of cutaneous malignancy.

Download Full-text

The Endoscopic Endonasal Transmaxillary Approach to Meckel's Cave Through the Inferior Orbital Fissure

Operative Neurosurgery ◽

10.1093/ons/opx009 ◽

2017 ◽

Vol 13 (3) ◽

pp. 367-373 ◽

Cited By ~ 2

Author(s):

Xin Zhang ◽

Halima Tabani ◽

Ivan El-Sayed ◽

Matthew Russell ◽

Xuequan Feng ◽

...

Keyword(s):

Infratemporal Fossa ◽

Middle Cranial Fossa ◽

Nasolacrimal Duct ◽

Neurovascular Bundle ◽

Infraorbital Nerve ◽

Meckel’S Cave ◽

Endoscopic Endonasal ◽

Maxillary Nerve ◽

Surgical Access ◽

Meckel's Cave

Abstract BACKGROUND: Surgical access to Meckel's Cave (MC) is challenging due to its deep location and surrounding important neurovascular structures. Currently existing endoscopic endonasal (EE) approaches require dissecting near the internal carotid artery (ICA) or require transposition of the pterygopalatine neurovascular bundle. OBJECTIVE: To describe a novel approach to access the anterolateral aspect of the MC using a minimally invasive EE route. METHODS: The EE transmaxillary transinferior orbital fissure approach was simulated in 10 specimens. The approach included an ethmoidectomy followed by an extended medial maxillectomy with transposition of the nasolacrimal duct. The infraorbital fissure was opened, and the infraorbital neurovascular bundle was transposed inferiorly. A quadrilateral space, bound by the maxillary nerve inferomedially, ophthalmic nerve superomedially, infraorbital nerve inferolaterally, and floor of the orbit superolaterally, was exposed. The distances from the foramen rotundum (FR) to the ICA, orbital apex (OA), and infratemporal crest (ITC) and from the OA to the ICA and ITC were measured. RESULTS: The distances obtained were FR-ICA = 19.42 ± 2.03 mm, FR-ITC = 18.76 ± 1.75 mm, FR-OA = 8.54 ± 1.34 mm, OA-ITC = 19.78 ± 2.63 mm, and OA-ICA = 20.64 ± 142 mm. Two imaginary lines defining safety boundaries were observed between the paraclival ICA and OA, and between the OA and ITC (safety lines 1 and 2). CONCLUSION: The reported approach provides a less invasive route compared to contemporary approaches, allowing expanded views and manipulation anteromedial and anterolateral to MC. It may be safer than the existing approaches as it does not require transposition of the ICA, infratemporal fossa, and pterygopalatine fossa, and allows access to tumors located anteriorly on the floor of the middle cranial fossa.

Download Full-text

Endoscopic Endonasal Approach to Meckel's Cave

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0032-1313971 ◽

2012 ◽

Vol 73 (S 02) ◽

Author(s):

A. Karkas ◽

J. Keller ◽

P. Theodosopoulos ◽

L. Zimmer

Keyword(s):

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Meckel’S Cave ◽

Endoscopic Endonasal ◽

Meckel's Cave

Download Full-text

Endoscopic Endonasal Versus Transorbital Surgery for Middle Cranial Fossa Tumors: Comparison of Clinical Outcomes Based on Surgical Corridors

World Neurosurgery ◽

10.1016/j.wneu.2018.11.090 ◽

2019 ◽

Vol 122 ◽

pp. e1491-e1504 ◽

Cited By ~ 7

Author(s):

Min Ho Lee ◽

Sang Duk Hong ◽

Kyung In Woo ◽

Yoon-Duck Kim ◽

Jung Won Choi ◽

...

Keyword(s):

Clinical Outcomes ◽

Middle Cranial Fossa ◽

Endoscopic Endonasal ◽

Cranial Fossa

Download Full-text

The Endoscopic Endonasal Approach to the Meckel's Cave Tumors: Surgical Technique and Indications

World Neurosurgery ◽

10.1016/j.wneu.2014.08.003 ◽

2014 ◽

Vol 82 (6) ◽

pp. S155-S161 ◽

Cited By ~ 13

Author(s):

Emmanuel Jouanneau ◽

Emile Simon ◽

Timothée Jacquesson ◽

Marc Sindou ◽

Stéphane Tringali ◽

...

Keyword(s):

Surgical Technique ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Meckel’S Cave ◽

Endoscopic Endonasal ◽

Meckel's Cave

Download Full-text

Paratrigeminal, Paraclival, Precavernous, or All of the Above? A Circumferential Anatomical Study of the C3-C4 Transitional Segment of the Internal Carotid Artery

Operative Neurosurgery ◽

10.1093/ons/opx121 ◽

2017 ◽

Vol 14 (4) ◽

pp. 432-440 ◽

Cited By ~ 2

Author(s):

Eleonora Marcati ◽

Norberto Andaluz ◽

Sebastien C Froelich ◽

Lee A Zimmer ◽

James L Leach ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Cavernous Sinus ◽

Internal Carotid ◽

Anatomical Study ◽

Posterior Longitudinal Ligament ◽

Petrous Apex ◽

Meckel’S Cave ◽

Endoscopic Endonasal ◽

Meckel's Cave

Abstract BACKGROUND Although the term paraclival carotid pervades recent skull base literature, no clear consensus exists regarding boundaries or anatomical segments. OBJECTIVE To reconcile various internal carotid artery (ICA) nomenclatures for transcranial and endoscopic-endonasal perspectives, we reexamined the transition between lacerum (C3) and cavernous (C4) segments using a C1-C7 segments schema. In this cadaveric study, we obtained a 360°-circumferential view integrating histological, microsurgical, endoscopic, and neuroradiological analyses of this C3-C4 region and identified a distinct transitional segment. METHODS In 13 adult, silicone-injected, formalin-fixed cadaveric heads (26 sides), transcranial-extradural-subtemporal and endoscopic-endonasal CTguided dissections were performed. A quadrilateral area was noted medial to Meckel's cave between cranial nerve VI, anterolateral and posterolateral borders of the lateral-paratrigeminal aspect of the precavernous ICA, and posterior longitudinal ligament. Endoscopically, a medial-paraclival aspect was defined. Anatomical correlations were made with histological and neuroradiological slides. RESULTS We identified a distinct precavernous C3-C4 transitional segment. In 18 (69%) specimens, venous channels were absent at the quadrilateral area, on the paratrigeminal border of the precavernous ICA. A trigeminal membrane, seen consistently on the superior border of V2, defined the lateral aspect of the cavernous sinus floor. The medial aspect of the precavernous ICA corresponded with the paraclival ICA. CONCLUSION Our study revealing the juncture of 2 complementary borders of the ICA, endoscopic endonasal (paraclival) and transcranial (paratrigeminal), reconciles various nomenclature. A precavernous segment may clarify controversies about the paraclival ICA and support the concept of a “safe door” for lesions involving Meckel's cave, cavernous sinus, and petrous apex.

Download Full-text