scholarly journals The Transcrusal Approach

Neurosurgery ◽  
2010 ◽  
Vol 66 (5) ◽  
pp. 1017-1022 ◽  
Author(s):  
Michael G. Brandt ◽  
Justin Poirier ◽  
Brian Hughes ◽  
Stephen P. Lownie ◽  
Lorne S. Parnes
Keyword(s):  
Facial Nerve ◽  
Basilar Artery ◽  
Cranial Nerve ◽  
Significant Risk ◽  
Artery Aneurysm ◽  
Hearing Preservation ◽  
Petrous Apex ◽  
Nerve Preservation ◽  
Trigeminal Schwannoma ◽  
Transcrusal Approach

Abstract OBJECTIVE This study reviewed the experience and outcomes of 1 surgical team (L.S.P., S.P.L.) using the transcrusal approach. METHODS Ten-year retrospective review of 17 consecutive patients requiring transcrusal exposure of the petrous apex and upper brainstem was performed. The main outcome measures included hearing and facial nerve preservation as measured by standard audiography and postoperative assessment using the House-Brackmann scale. RESULTS Operative indications included meningioma (5 patients), epidermoid/dermoid cyst (3 patients), trigeminal schwannoma (3 patients), giant or large upper basilar artery aneurysm (3 patients), pontine cavernoma (1 patient), chondrosarcoma (1 patient), and clival melanocytoma (1 patient). Average tumor size was 3.6 cm. Complete resection was achieved in 50% of patients with petroclival tumors. Follow-up data were obtained for 14 patients at 20 ± 4 months. Serviceable hearing was preserved in 58%. Sixty-four percent of patients demonstrated House-Brackmann stage I facial nerve function. Two patients died perioperatively (brainstem infarction). Two patients became hemiparetic, with 1 improving substantially. CSF leaks developed in 3 patients. Forty-seven percent of patients demonstrated cranial nerve V deficits. Forty-one percent of patients demonstrated deficits of cranial nerve III, IV, or VI. Vertigo, vestibular disturbance, hydrocephalus, temporal lobe contusion, or hematoma did not develop in any patients. CONCLUSION The transcrusal approach provides adequate exposure for most petroclival lesions and giant aneurysms of the upper basilar artery while offering the possibility of hearing preservation. Like all approaches to large tumors and aneurysms in this region, there is a significant risk of morbidity and mortality. However, this approach is an excellent alternative to other techniques that necessitate deliberate sacrifice of ipsilateral hearing.

766 Endoscopic Surgery for Sporadic Vestibular Schwannoma Resection: A Systematic Review of Surgical Outcomes

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
S Chiuta ◽  
S Raza-Knight ◽  
A Alalade
Keyword(s):  
Facial Nerve ◽  
Hearing Preservation ◽  
Extent Of Resection ◽  
Current Data ◽  
Resection Rate ◽  
Eighth Cranial Nerve ◽  
Nerve Preservation ◽  
Microsurgical Resection ◽  
Hearing Outcomes ◽  
Series Report

Abstract Introduction Vestibular schwannomas (VS) are benign intracranial tumours originating from the vestibular division of the eighth cranial nerve. The mainstay of their surgical management is microsurgery, other options are radiotherapy or radiological monitoring. Endoscopy (ES) is becoming widely used in neurosurgery and may have a role in improving visualisation and outcomes by enhancing extent of resection, facial nerve, and hearing preservation in VS resection and describe the postoperative outcomes. Method The review was conducted according to the PRISMA guidelines and yielded 31 studies for inclusion. Systematic searches of literature databases were done for studies where endoscopic-assisted and/or endoscopic resection of VS were reported. Results ES facial nerve preservation rates (median 91.3%, range 39.0 - 100%) were comparable to microsurgical treatment. Hearing outcomes were more variable in ES series and were under-reported. A median gross total resection rate of 97.4% (61.0 - 100%) was achieved in the ES series. Conclusions Current data suggest that ES-assisted resection of sporadic VS is not inferior to microsurgical resection with respect to facial nerve outcomes and extent of resection. However, some ES series report poor hearing outcomes, which are under-reported in the literature.

scholarly journals Presigmoid Approach to Dumbbell Trigeminal Schwannoma

2018 ◽  
Vol 79 (S 05) ◽  
pp. S391-S392
Author(s):  
Katherine Kunigelis ◽  
Daniel Craig ◽  
Alexander Yang ◽  
Samuel Gubbels ◽  
A. Youssef
Keyword(s):  
Trigeminal Nerve ◽  
Treatment Options ◽  
Extent Of Resection ◽  
Direct Access ◽  
Petrous Apex ◽  
Total Resection ◽  
Middle Fossa Approach ◽  
Nerve Preservation ◽  
Presigmoid Approach ◽  
Trigeminal Schwannoma

This case is a 15-year-old male, presenting with headaches, right face, and arm numbness, and ataxia. MRI (magnetic resonance imaging) revealed a large right sided dumbbell shaped lesion, extending into the middle and posterior fossa with compression of the brainstem consistent with a trigeminal schwannoma. Treatment options here would be a retrosigmoid suprameatal approach or a lateral presigmoid approach. Given the tumor extension into multiple compartments, a presigmoid craniotomy, combining a middle fossa approach with anterior petrosectomy, and retrolabyrinthine approach with posterior petrosectomy were used to maximize the direct access corridor for resection. The petrous apex was already expanded and remodeled by the tumor. Nerve fascicles preservation technique is paramount to the functional preservation of the trigeminal nerve. The extent of resection should be weighed against the anatomical functional integrity of the nerve. Near total resection is considered if that means more nerve preservation. Postoperatively, the patient had a slight (House–Brackman grade II) facial droop, which resolved over days and developed right trigeminal hypesthesia at several weeks. This case is presented to demonstrate a combined petrosectomy technique for resection of lesions extending into both the middle and posterior cranial fossa with near total resection and trigeminal nerve preservation.The link to the video can be found at: https://youtu.be/kA9GyFhL1dg.

scholarly journals Intraoperative neurophysiological monitoring in vestibular schwannoma surgery: advances and clinical implications

2009 ◽  
Vol 27 (4) ◽  
pp. E9 ◽  
Author(s):  
A. Samy Youssef ◽  
Angela E. Downes
Keyword(s):  
Facial Nerve ◽  
Functional Outcome ◽  
Vestibular Schwannoma ◽  
Cranial Nerve ◽  
Evoked Potential ◽  
Hearing Preservation ◽  
Auditory Evoked Potential ◽  
Intraoperative Neurophysiological Monitoring ◽  
Neurophysiological Monitoring ◽  
Clinical Series

Object Intraoperative neurophysiological monitoring has become an integral part of vestibular schwannoma surgery. The aim of this article was to review the different techniques of intraoperative neurophysiological monitoring in vestibular schwannoma surgery, identify the clinical impact of certain pathognomonic patterns on postoperative outcomes of facial nerve function and hearing preservation, and highlight the role of postoperative medications in improving delayed cranial nerve dysfunction in the different reported series. Methods The authors performed a review of the literature regarding intraoperative monitoring in acoustic/vestibular schwannoma surgery. The different clinical series representing different monitoring techniques were reviewed. All the data from clinical series were analyzed in a comprehensive and comparative model. Results Intraoperative brainstem auditory evoked potential monitoring, direct cochlear nerve action potential monitoring, and facial nerve electromyography are the main tools used to assess the functional integrity of an anatomically intact cranial nerve. The identification of pathognomonic brainstem auditory evoked potential and electromyography patterns has been correlated with postoperative functional outcome. Recently, perioperative administration of intravenous hydroxyethyl starch and nimodipine as vasoactive and neuroprotective agents was shown to improve vestibular schwannoma functional outcome in few reported studies. Conclusions Recent advances in electrophysiological technology have considerably contributed to improvement in functional outcome of vestibular neuroma surgery in terms of hearing preservation and facial nerve paresis. Perioperative intravenous nimodipine and hydroxyethyl starch may be valuable additions to surgery.

scholarly journals How I Do It: The Role of Flexible Hand-held 2μ-Thulium Laser Fiber in Microsurgical Removal of Acoustic Neuromas

2017 ◽  
Vol 78 (04) ◽  
pp. 301-307 ◽  
Author(s):  
Guglielmo Cacciotti ◽  
Raffaele Roperto ◽  
Maria Tonelli ◽  
Ettore Carpineta ◽  
Luciano Mastronardi
Keyword(s):  
Facial Nerve ◽  
Tumor Resection ◽  
Hearing Preservation ◽  
Matched Pair ◽  
Nerve Preservation ◽  
Acoustic Neuromas ◽  
Laser Fiber ◽  
Laser Focusing ◽  
Preservation Rate

Aims We performed a retrospective nonrandomized study to analyze the results of microsurgery of acoustic neuromas (AN) using 2μ-thulium flexible hand-held laser fiber (Revolix jr). Methods From September 2010 to September 2015, 89 patients suffering from AN have been operated on with microsurgical technique via retrosigmoid approach. In 37 cases, tumor resection was performed with the assistance of 2μ-thulium flexible hand-held laser fiber (L-group). Eight cases operated on with the assistance of CO2 hand-held flexible laser fiber were excluded from this study. A total of 44 patients, operated on without laser assistance during the same period, were used as comparison group (C-group) (matched pair technique). Facial nerve function was assessed with the House–Brackmann (HB) scale preoperatively, and 1 week and 6 months postoperatively. Results Overall time from incision to skin suture changed in relation to size of tumor (165–575 minutes) and was not affected by the use of laser. In 7 out of 81 cases, a preoperative facial nerve palsy HB2 and in 1 case, HB4 (permanent) were observed. In the remaining 80 cases, at 6-month follow-up, facial nerve preservation rate (HB1) was 92.5%. Hearing preservation rate (AAO-HNS A/B classes) was 68.2% (26 out of 36). Adopting a 0 to 3 scale, the mean surgeon satisfaction rate of usefulness of laser fiber was 2.7. Conclusion The use of 2μ-thulium hand-held flexible laser fiber in AN microsurgery seems to be safe and subjectively facilitates tumor resection especially in “difficult” conditions (e.g., highly vascularized and hard tumors). In this limited retrospective trial, the good functional outcome following conventional microsurgery had not further improved, nor the surgical time reduced by laser. Focusing its use on “difficult” (large and vascularized) cases may lead to different results in future.

scholarly journals The extradural temporopolar approach: a review of indications and operative technique

2008 ◽  
Vol 25 (6) ◽  
pp. E3 ◽  
Author(s):  
Gabriel Zada ◽  
J. Diaz Day ◽  
Steven L. Giannotta
Keyword(s):  
Cavernous Sinus ◽  
Basilar Artery ◽  
Operative Technique ◽  
Cranial Nerves ◽  
Artery Aneurysm ◽  
Lateral Wall ◽  
Superior Cerebellar Artery ◽  
Trigeminal Schwannoma ◽  
Cerebellar Artery ◽  
Brain Retraction

Object The extradural temporopolar approach is used for enhanced exposure of the cavernous sinus and petroclival regions in the treatment of complex lesions not amenable to sole treatment via radiosurgical or endovascular methods. The authors' objective was to review the indications, surgical experience, and operative technique in a series of patients who underwent surgery with this approach. Methods The authors conducted a retrospective review to identify patients who underwent a temporopolar approach from 1992 to 2008. An orbitozygomatic craniotomy was frequently used, followed by extradural retraction of the temporal lobe. A sequential progression of bone removal at the anterior and middle skull base, followed by opening the layers of the lateral wall of the cavernous sinus was next performed to safely retract the brain and widen the exposure to the cavernous sinus, interpeduncular fossa, and upper petroclival regions. Results Sixty-six patients were identified and included in the study. The mean patient age was 49 years. The main indications for surgery were as follows: meningioma (25 patients, 38%), basilar artery aneurysm (11 patients, 17%), trigeminal schwannoma (7 patients, 11%), chordoma (5 patients, 7%), hemangioma (3 patients, 5%), pituitary adenoma (3 patients, 5%), superior cerebellar artery aneurysm (3 patients, 5%), and other lesions (9 patients, 14%). Complications included hemiparesis in 4 patients (6%), infarcts in 4 patients (6%), transient aphasia in 1 patient (1.5%), and cranial nerve paresis in 20 patients (30%). Conclusions The extradural temporopolar approach offers a relatively safe and wide exposure of the sphenocavernous and petroclival regions. Mobilization of the cranial nerves and internal carotid artery allow gentle brain retraction and maximal preservation of venous outflow. This is an advantageous approach to large tumors in these regions and for complex upper basilar artery or superior cerebellar artery aneurysms.

Type 2 neurofibromatosis: the need for supraregional care?

1993 ◽  
Vol 107 (5) ◽  
pp. 401-406 ◽  
Author(s):  
D. Gareth R. Evans ◽  
Richard Ramsden ◽  
Susan M. Huson ◽  
Rodney Harris ◽  
Richard Lye ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Vestibular Schwannoma ◽  
Acoustic Neuroma ◽  
Hearing Preservation ◽  
Definitive Treatment ◽  
Facial Nerve Function ◽  
Operative Results ◽  
Nerve Preservation ◽  
Quality Life

The results of a U.K. study of 145 cases of type 2 neurofibromatosis has shown generally very poor operative results in terms of hearing and facial nerve preservation. Only 9 out of 118 vestibular schwannoma (acoustic neuroma) operations resulted in any clinically detectable hearing preservation and only 32 left the patient with good or normal (House grade I or II) ipsilateral facial nerve function. Although operation is still the definitive treatment of vestibular schwannoma (acoustic neuroma) and may be a lifesaving procedure, it appears that the evidence in favour of early operation is only valid when carried out in highly specialized centres. The special problems of NF2 cases who may go on to develop multiple spinal and cranial tumours making them wheelchair bound and blind as well as deaf warrants a careful experienced approach. Timing of operations may be critical for the enhancement of useful years of quality life. We therefore propose the setting up of a national NF2 register, with the management of cases at a few supraregional centres.

Improved preservation of hearing and facial nerve function in vestibular schwannoma surgery via the retrosigmoid approach in a series of 200 patients

2006 ◽  
Vol 105 (4) ◽  
pp. 527-535 ◽  
Author(s):  
Madjid Samii ◽  
Venelin Gerganov ◽  
Amir Samii
Keyword(s):  
Facial Nerve ◽  
Hearing Preservation ◽  
Neurological Status ◽  
Retrosigmoid Approach ◽  
Cerebrospinal Fluid Leakage ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Nerve Preservation ◽  
Permanent Morbidity

Object The aim of this study was to evaluate and present the results of current surgical treatment of vestibular schwannomas (VSs) and to report the refinements in the operative technique. Methods The authors performed a retrospective study of 200 consecutive patients who had undergone VS surgery over a 3-year period. Patient records, operative reports, follow-up data, and neuroradiological findings were analyzed. The main outcome measures were magnetic resonance imaging, neurological status, patient complaints, and surgical complications. Complete tumor removal was achieved in 98% of patients. Anatomical preservation of the facial nerve was possible in 98.5% of patients. In patients treated for tumors with extension Classes T1, T2, and T3, the rate of facial nerve preservation was 100%. By the last follow-up examination, excellent or good facial nerve function had been achieved in 81% of the cases. By at least 1 year postsurgery, no patients had total facial palsy. In the patients with preserved hearing, the rate of anatomical preservation of the cochlear nerve was 84%. The overall rate of functional hearing preservation was 51%. There was no surgery-related permanent morbidity in this series of patients. Cerebrospinal fluid leakage was diagnosed in 2% of the patients. The mortality rate was 0%. Conclusions The goal of VS treatment should be total removal in one stage and preservation of neurological function, as they determine a patient’s quality of life. This goal can be safely and successfully achieved using the retrosigmoid approach.

Implications of Cystic Features in Vestibular Schwannomas of Patients Undergoing Microsurgical Resection

Neurosurgery ◽  
2011 ◽  
Vol 68 (4) ◽  
pp. 874-880 ◽  
Author(s):  
Brian J. Jian ◽  
Michael E. Sughrue ◽  
Rajwant Kaur ◽  
Martin J. Rutkowski ◽  
Ari J. Kane ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Postoperative Outcome ◽  
Hearing Preservation ◽  
Neck Surgery ◽  
Vestibular Schwannomas ◽  
Nerve Preservation ◽  
Cystic Tumors ◽  
Cystic Changes ◽  
Microsurgical Resection ◽  
Nerve Dysfunction

Abstract BACKGROUND: Cystic vestibular schwannomas (VSs) are described as being more aggressive than solid tumors. OBJECTIVE: We examined 468 VS patients to evaluate whether the presence of cystic components in VSs may be an important feature for predicting postoperative outcome. METHODS: We selected all VS patients from a prospectively collected database (1984–2009) who underwent microsurgical resection for VS. Hearing data were analyzed using American Association of Otolaryngology–Head and Neck Surgery. Facial nerve dysfunction was analyzed using the House-Brackmann scale. We used univariate comparisons to determine the clinical impact of cystic changes on preoperative and postsurgical hearing and facial nerve preservation. RESULTS: We identified 58 patients (11%) with cystic changes and 410 patients with solid VSs. In this analysis, cystic VS patients tended to have larger tumors (78% of patients with >2.0 cm extrameatal extension) compared with the solid VS group, which consisted of many smaller and medium-sized tumors (P < .0001). Univariate analyses found that tumors with cystic changes did not lead to worse rates of preoperative hearing loss (χ2, P = not significant) compared with solid VSs. Cystic changes conferred worse postoperative hearing in patients with medium-sized tumors (P = .035). Cystic changes also did not significantly affect facial nerve outcomes (χ2, P = not significant). CONCLUSION: Cystic tumors tend to be larger than noncystic tumors and affect outcomes by reducing the rate at which hearing preservation is attempted and by worsening hearing outcome in medium-sized tumors. Further, peripheral cysts cause lower rates of hearing preservation compared with centrally located cysts.

scholarly journals Retrosigmoid approach for giant cystic vestibular schwannoma: subperineural dissection technique for facial nerve preservation

2021 ◽  
Vol 5 (2) ◽  
pp. V7
Author(s):  
Ali Tayebi Meybodi ◽  
Robert W. Jyung ◽  
James K. Liu
Keyword(s):  
Facial Nerve ◽  
Thin Layer ◽  
Vestibular Schwannoma ◽  
Cranial Nerve ◽  
Retrosigmoid Approach ◽  
Nerve Function ◽  
Facial Nerve Function ◽  
Total Resection ◽  
Nerve Preservation ◽  
Dissection Technique

In this illustrative video, the authors demonstrate retrosigmoid resection of a giant cystic vestibular schwannoma using the subperineural dissection technique to preserve facial nerve function. This thin layer of perineurium arising from the vestibular nerves is used as a protective buffer to shield the facial and cochlear nerves from direct microdissection trauma. A near-total resection was achieved, and the patient had an immediate postoperative House-Brackmann grade I facial nerve function. The operative nuances and pearls of technique for safe cranial nerve and brainstem dissection, as well as the intraoperative decision and technique to leave the least amount of residual adherent tumor, are demonstrated. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21128

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