Fatal hemorrhagic complication after coil embolization of a petrosal arteriovenous shunt

2021 ◽  
pp. 159101992110577
Author(s):  
David Volders ◽  
Elena Adela Cora ◽  
Chiraz Chaalala ◽  
Maxime Cartier ◽  
Michihiro Tanaka ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Coil Embolization ◽  
Arteriovenous Shunt ◽  
Embolic Agent ◽  
Petrous Apex ◽  
Hemorrhagic Complication ◽  
Contrast Extravasation ◽  
Petrosal Vein ◽  
Hemorrhagic Risk ◽  
Superior Petrosal Sinus

Background Cerebello-pontine AVMs (CPAVMs) and petrous apex dural arteriovenous fistulae (DAVFs) are rare and sometimes difficult to distinguish. We report a fatal hemorrhagic complication after coil embolization of the petrosal vein draining a trigeminal AVM misdiagnosed as a DAVF. Case presentation A 73-year-old woman with a petrous apex arteriovenous shunt with dual dural and pial arterial supply presented with posterior fossa hemorrhage. The draining petrosal vein was catheterized and coiled via the superior petrosal sinus. Two episodes of contrast extravasation occurred during coiling, but the lesion was completely occluded at the end of the procedure. The patient developed a fatal posterior fossa hemorrhage in the recovery room. Microscopic pathology revealed numerous dilated vessels within the trigeminal nerve. Conclusion CPAVMs and DAVFs with pial drainage should be distinguished pre-operatively. Occlusion of a pial vein (as opposed to a sinus) in the treatment of an arteriovenous shunt carries hemorrhagic risk if a liquid embolic agent is not used to completely occlude all pathological vessels.

scholarly journals Petrosal Approach With Preservation of the Superior Petrosal Sinus (the Graceful Petrosal) for Resection of Giant Trigeminal Schwannoma: 2-Dimensional Operative Video

2021 ◽  
Vol 20 (5) ◽  
pp. E342-E343
Author(s):  
Kaith K Almefty ◽  
Ossama Al-Mefty
Keyword(s):  
Magnetic Resonance ◽  
Surgical Resection ◽  
Posterior Fossa ◽  
Tumor Resection ◽  
Venous Drainage ◽  
Petrous Apex ◽  
Benign Tumors ◽  
Nerve Function ◽  
Trigeminal Schwannoma ◽  
Superior Petrosal Sinus

Abstract Trigeminal schwannomas are benign tumors amendable to curative surgical resection.1 Excellent outcomes, with preservation and improvement of cranial nerve function, including trigeminal nerve function, have been reported with microsurgical resection through skull base approaches.2 Dumbell shaped tumors, involving the middle and posterior fossa, are more challenging.3 They are resected via a middle cranial fossa approach with the expanded Meckel cave providing access to the posterior fossa. However, tumors with a large caudal extension below the internal auditory meatus typically cannot be adequately accessed with this approach and the posterior petrosal approach is utilized.2 Specific venous anatomy might deter from cutting the tentorium. This article describes the surgical resection of a trigeminal schwannoma with a large posterior fossa component through a petrosal approach without cutting the tentorium.4 The patient is a 34-yr-old man who presented with headaches and gait disturbance. Neurological exam revealed hypoesthesia and hypoalgesia in the left V1 and V2 distributions. Magnetic resonance imaging (MRI) revealed a large dumbbell-shaped schwannoma causing brainstem compression. Magnetic resonance venography (MRV) demonstrated temporal lobe venous drainage into the superior petrosal sinus and tentorium proximal to the transverse sigmoid junction. A single temporal-suboccipital bone flap and a retro-labrynthine mastoidectomy were performed. The petrous apex was drilled and Meckle's cave opened. The presigmoid dura was opened and extended toward the petrous apex region beneath the tentorium. This provided access to and safe resection of the tumor. A gross total tumor resection was achieved. The patient remained stable neurologically and was without tumor recurrence at 3 yr postoperatively. The patient had consented to the procedure. Figures in video at 4:06 from Jafez et al, Preservation of the superior petrosal sinus during the petrosal approach, J Neurosurg. 2011;114(5):1294-1298, with permission from JNSPG.

Combined Transpetrosal Approach With Preservation of Superior Petrosal Vein Drainage for a Cerebellopontine Angle Epidermoid Cyst Extending Into Meckel's Cave: 3-Dimensional Operative Video

2018 ◽  
Vol 16 (6) ◽  
pp. E172-E173
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno ◽  
Nobuyuki Nakajima ◽  
Norio Ichimasu
Keyword(s):  
Epidermoid Cyst ◽  
Cerebellopontine Angle ◽  
Young Patients ◽  
Neurological Deficits ◽  
Meckel’S Cave ◽  
3 Dimensional ◽  
Petrosal Vein ◽  
Meckel's Cave ◽  
Superior Petrosal Sinus ◽  
Superior Petrosal Vein

Abstract The combined transpetrosal approach enables wide exposure around the petroclival region by cutting the tentorium and superior petrosal sinus. We often choose this approach for removal of tumors ventral to the facial and vestibulocochlear nerves, such as petroclival meningioma and epidermoid cyst, because complete removal of the tumor under direct visualization is required to prevent its later recurrence, especially in young patients. Recent reports revealed anatomical variations of the drainage of the superior petrosal sinus, and dural incision considering preservation of the superior petrosal vein was proposed.1-3 This 3-dimensional video shows a patient with an epidermoid cyst, which was surgically treated using the combined transpetrosal approach, with consideration of the variation of the superior petrosal sinus and preservation of the drainage route of the superior petrosal vein. The video was reproduced after informed consent of the patient. The patient is a 31-yr-old woman who presented with a left cerebellopontine angle epidermoid cyst extending into Meckel's cave. The superior petrosal sinus was of the lateral type, draining only laterally into the transverse–sigmoid junction without medial connection with the cavernous sinus.1 The combined transpetrosal approach was performed with cutting of the superior petrosal sinus medial to the entry point of the superior petrosal vein, in order to preserve its drainage into the transverse–sigmoid junction. Meckel’ cave was opened along its lateral margin, and tumor removal was accomplished, leaving only a minute part of the capsule strongly adhering to the neurovascular structures. The patient had no new permanent neurological deficits during follow-up. The figures in the video were modified from Matsushima et al1 by permission of the Congress of Neurological Surgeons.

Epidermoid Cysts and Cholesterol Granulomas Centered on the Posterior Fossa: Twenty Years of Diagnosis and Management

Neurosurgery ◽  
1987 ◽  
Vol 21 (6) ◽  
pp. 798-805 ◽  
Author(s):  
Howard Ian Sabin ◽  
Lorenzo Tommaso Bordi ◽  
Lindsay Symon
Keyword(s):  
Posterior Fossa ◽  
Diagnostic Procedures ◽  
Jugular Foramen ◽  
Neurological Deficits ◽  
Petrous Apex ◽  
Epidermoid Cysts ◽  
Diagnosis And Management ◽  
Presenting Symptoms ◽  
Review Period ◽  
Contrast Ventriculography

Abstract The clinical features, diagnosis, and management of 23 posterior fossa epidermoid cysts and 9 petrous apex lesions presenting to one unit over a period of 20 years are summarized. Of the epidermoid cysts, 13 were entirely infratentorial, but the other 10 had an additional supratentorial component. Presenting symptoms and signs were usually long-standing and at onset had often been vague and nonspecific. With time, however, a variety of neurological deficits that depended on the site of the lesion developed. These were generally combinations of cerebellopontine (CP) angle and jugular foramen syndromes, deafness, facial palsy, and motor weakness. Diagnostic procedures have changed greatly over the review period. Computed tomography and magnetic resonance imaging have replaced air encephalography and contrast ventriculography. The better preoperative localization of these lesions allows rational planning of the surgical approach required for optimal tumor exposure, which is essential for any attempt at total excision, considering the large size of the majority of these tumors when diagnosed. We favor operation through a posterior fossa craniectomy for those tumors restricted to the CP angle or 4th ventricle, but routinely use a combined supra- and infratentorial approach if the lesion has a more rostral component. The infiltrating nature of epidermoid cysts within the cranium compromises the extent of excision if neurological deficit is not to be increased, but we attempt as complete an excision of tumor and capsule as possible in the hope that many years will pass before symptoms recur. Cholesterol granulomas seem to respond well to simple cavity drainage and have shown no tendency to recur.

scholarly journals Endoscopic endonasal surgical management of chondrosarcomas with cerebellopontine angle extension

2014 ◽  
Vol 37 (4) ◽  
pp. E13 ◽  
Author(s):  
Paulo M. Mesquita Filho ◽  
Leo F. S. Ditzel Filho ◽  
Daniel M. Prevedello ◽  
Cristian A. N. Martinez ◽  
Mariano E. Fiore ◽  
...  
Keyword(s):  
Skull Base ◽  
Posterior Fossa ◽  
Cerebellopontine Angle ◽  
Tumor Resection ◽  
Petrous Bone ◽  
Petrous Apex ◽  
Total Resection ◽  
Endoscopic Endonasal ◽  
Female Ratio ◽  
Male Female Ratio

Object Skull base chondrosarcomas are slow-growing, locally invasive tumors that arise from the petroclival synchondrosis. These characteristics allow them to erode the clivus and petrous bone and slowly compress the contents of the posterior fossa progressively until the patient becomes symptomatic, typically from cranial neuropathies. Given the site of their genesis, surrounded by the petrous apex and the clival recess, these tumors can project to the middle fossa, cervical area, and posteriorly, toward the cerebellopontine angle (CPA). Expanded endoscopic endonasal approaches are versatile techniques that grant access to the petroclival synchondrosis, the core of these lesions. The ability to access multiple compartments, remove infiltrated bone, and achieve tumor resection without the need for neural retraction makes these techniques particularly appealing in the management of these complex lesions. Methods Analysis of the authors’ database yielded 19 cases of skull base chondrosarcomas; among these were 5 cases with predominant CPA involvement. The electronic medical records of the 5 patients were retrospectively reviewed for age, sex, presentation, pre- and postoperative imaging, surgical technique, pathology, and follow-up. These cases were used to illustrate the surgical nuances involved in the endonasal resection of CPA chondrosarcomas. Results The male/female ratio was 1:4, and the patients’ mean age was 55.2 ±11.2 years. All cases involved petrous bone and apex, with variable extensions to the posterior fossa and parapharyngeal space. The main clinical scenario was cranial nerve (CN) palsy, evidenced by diplopia (20%), ptosis (20%), CN VI palsy (20%), dysphagia (40%), impaired phonation (40%), hearing loss (20%), tinnitus (20%), and vertigo/dizziness (40%). Gross-total resection of the CPA component of the tumor was achieved in 4 cases (80%); near-total resection of the CPA component was performed in 1 case (20%). Two patients (40%) harbored high-grade chondrosarcomas. No patient experienced worsening neurological symptoms postoperatively. In 2 cases (40%), the symptoms were completely normalized after surgery. Conclusions Expanded endoscopic endonasal approaches appear to be safe and effective in the resection of select skull base chondrosarcomas; those with predominant CPA involvement seem particularly amenable to resection through this technique. Further studies with larger cohorts are necessary to test these preliminary impressions and to compare their effectiveness with the results obtained with open approaches.

The Subtemporal Interdural Approach to Dumbbell-Shaped Trigeminal Schwannomas: Cadaveric Prosection

2006 ◽  
Vol 59 (suppl_4) ◽  
pp. ONS-270-ONS-278 ◽  
Author(s):  
Samy Youssef ◽  
Eun-Young Kim ◽  
Khaled M.A. Aziz ◽  
Salah Hemida ◽  
Jeffrey T. Keller ◽  
...  
Keyword(s):  
Cleavage Plane ◽  
Histological Study ◽  
Petrous Apex ◽  
Gasserian Ganglion ◽  
Middle Fossa ◽  
Meckel’S Cave ◽  
Anterior Transpetrosal Approach ◽  
Single Compartment ◽  
Meckel's Cave ◽  
Superior Petrosal Sinus

Abstract OBJECTIVE: Successful resection of dumbbell-shaped trigeminal schwannomas via a subtemporal interdural approach requires an understanding of both the anatomy related to the bone dissection of the petrous apex (Kawase's triangle or quadrilateral) and meningeal anatomy. We studied the meningeal anatomy related to this approach and describe the dural incisions and stepwise mobilization. METHODS: Meningeal anatomy around Meckel's cave and porus trigeminus was examined during the subtemporal interdural anterior transpetrosal approach in both sides of 15 cadaveric heads. Histological study of the Meckel's cave region was performed in two cadaveric heads. RESULTS: The Gasserian ganglion and trigeminal roots have two layers of dura propria on their dorsolateral surface: an inner layer from the posterior fossa dura propria that constitutes the dorsolateral wall of Meckel's cave and an outer layer from the dura propria of the middle fossa. The cleavage plane between these two layers continues distally as the cleavage plane between the epineural sheaths of the trigeminal divisions and the dura propria of the middle fossa. This cleavage plane serves as the anatomic landmark for the interdural exposure of the contents of Meckel's cave. The superior petrosal sinus is sectioned at the medial aspect of Kawase's triangle and reflected along with the porus trigeminus roof. CONCLUSION: Understanding the critical meningeal architecture in and around Meckel's cave allows experienced cranial neurosurgeons to develop a subtemporal interdural approach to dumbbell-shaped trigeminal schwannomas that effectively converts a multiple-compartment tumor into a single-compartment tumor. Dural incisions and stepwise mobilization complements our previous description of the bony dissection for this approach.

Combined transarterial N-butyl cyanoacrylate and coil embolization of direct carotid–cavernous fistulas

2007 ◽  
Vol 106 (5) ◽  
pp. 903-906 ◽  
Author(s):  
Neil A. Troffkin ◽  
Curtis A. Given
Keyword(s):  
Carotid Artery ◽  
Coil Embolization ◽  
Nerve Palsy ◽  
Embolic Agent ◽  
Cyanoacrylate Glue ◽  
Complete Occlusion ◽  
Liquid Embolic ◽  
Liquid Embolic Agent ◽  
Carotid Cavernous Fistulas ◽  
Complex Cases

✓ The authors report two cases of traumatic carotid–cavernous fistulas treated successfully with combined N-butyl cyanoacrylate glue and coil embolization via a transarterial approach. In both cases complete occlusion of the fistula was achieved, with preservation of the parent carotid artery. Casting of the cavernous sinus with a liquid embolic agent was well tolerated and produced no complications of cranial nerve palsy. This technique provides interventionalists with yet another treatment option in these often complex cases.

Clinical and Neurophysiological Observations after Superior Petrosal Vein Obstruction during Surgery of the Cerebellopontine Angle: Case Report

Neurosurgery ◽  
2001 ◽  
Vol 48 (5) ◽  
pp. 1157-1161 ◽  
Author(s):  
Christian Strauss ◽  
Mandana Neu ◽  
Barbara Bischoff ◽  
Johann Romstöck
Keyword(s):  
Evoked Potentials ◽  
Cerebellopontine Angle ◽  
Auditory Evoked Potentials ◽  
Venous Drainage ◽  
Lateral Approach ◽  
Petrous Apex ◽  
Brainstem Auditory Evoked Potentials ◽  
Petrosal Vein ◽  
Superior Petrosal Vein ◽  
Temporary Clipping

Abstract IMPORTANCE Preservation of venous drainage during surgery of the cerebellopontine angle has received little attention. CLINICAL PRESENTATION We describe changes in brainstem auditory evoked potentials after temporary obstruction of the superior petrosal vein during surgical resection of a small meningioma at the petrous apex via a standard suboccipital-lateral approach. Temporary clipping of the petrosal vein resulted in deterioration of the brainstem auditory evoked potentials. The tumor was removed with preservation of the superior petrosal vein. CONCLUSION A transient postoperative cochlear nerve deficit emphasizes the importance of venous drainage and its preservation during surgery for small lesions of the cerebellopontine angle that do not distort normal anatomic structures.

scholarly journals Posterior Fossa Venous Drainage

2021 ◽  
Vol 12 ◽  
Author(s):  
María Angeles de Miquel
Keyword(s):  
Posterior Fossa ◽  
Special Interest ◽  
Fetal Development ◽  
Venous Drainage ◽  
Inferior Petrosal Sinus ◽  
Vein Of Galen ◽  
Venous Anatomy ◽  
Anatomical Structures ◽  
Superior Petrosal Sinus

This paper aims to make simple the evaluation of the main veins related to the brainstem and cerebellum. Posterior fossa venous drainage is best understood in context with its three main collectors: superior: toward the Vein of Galen; posterior: toward the torcular complex; and anterior: toward the superior petrosal sinus. A fourth possible drainage path, often harder to distinguish, is directed toward the inferior petrosal sinus. Veins of these four systems are frequently connected to one another. Despite traditionally being considered less regular than its arterial disposition, posterior fossa venous anatomy follows specific patterns that are easy to identify. The three more representative veins of each venous confluent have been selected, to help in recognizing them angiographically. Since pial large veins are primarily located over the surface of the encephalon, most related anatomical structures can be confidently identified. This is of special interest when angiographic 2D or 3D studies are evaluated and provide fundamental assistance in locating precise structures. To better aid in understanding venous disposition, an overview of embryologic and fetal development is also discussed.

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