“Far-Medial” Expanded Endonasal Approach to the Inferior Third of the Clivus

2010 ◽  
Vol 66 (suppl_2) ◽  
pp. ons211-ons220 ◽  
Author(s):  
Victor A. Morera ◽  
Juan C. Fernandez-Miranda ◽  
Daniel M. Prevedello ◽  
Ricky Madhok ◽  
Juan Barges-Coll ◽  
...  
Keyword(s):  
Cranial Nerves ◽  
Foramen Magnum ◽  
Direct Access ◽  
Occipital Condyle ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Hypoglossal Canal ◽  
Expanded Endonasal Approach ◽  
Surgical Corridor ◽  
Lower Cranial Nerves

Abstract OBJECTIVE The endoscopic endonasal transclival approach is a valid alternative for treatment of lesions in the clivus. The major limitation of this approach is a significant lateral extension of the tumor. We aim to identify a safe corridor through the occipital condyle to provide more lateral exposure of the foramen magnum. METHODS Sixteen parameters were measured in 25 adult skulls to analyze the exact extension of a safe corridor through the condyle. Endonasal endoscopic anatomic dissections were carried out in nine colored latex–injected heads. RESULTS Drilling at the lateral inferior clival area exposed two compartments divided by the hypoglossal canal: the jugular tubercle (superior) and the condylar (inferior). Completion of a unilateral ventromedial condyle resection opens a 3.5 mm (transverse length) * 10 mm (vertical length) lateral surgical corridor, facilitating direct access to the vertebral artery at its dural entry point into the posterior fossa. The supracondylar groove is a reliable landmark for locating the hypoglossal canal in relation to the condyle. The hypoglossal canal is used as the posterior limit of the condyle removal to preserve more than half of the condylar mass. The transjugular tubercle approach is accomplished by drilling above the hypoglossal canal, and increases the vertical length of the lateral surgical corridor by 8 mm, allowing for visualization of the distal cisternal segment of the lower cranial nerves. CONCLUSION The transcondylar and transjugular tubercle “far medial” expansions of the endoscopic endonasal approach to the inferior third of the clivus provide a unique surgical corridor to the ventrolateral surface of the ponto- and cervicomedullary junctions.

scholarly journals Endoscopic Endonasal Approach to Foramen Magnum Meningioma—Technical Note and Case Example

2018 ◽  
Vol 37 (04) ◽  
pp. 362-366
Author(s):  
Flavio Romero ◽  
Rodolfo Vieira ◽  
Bruno Ancheschi
Keyword(s):  
Cranial Nerves ◽  
Craniocervical Junction ◽  
Foramen Magnum ◽  
Technical Note ◽  
Open Approach ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Midline Approach ◽  
Lower Cranial Nerves

AbstractForamen magnum (FM) tumors represent one of the most complex cases for the neurosurgeon, due to their location in a very anatomically complex region surrounded by the brainstem and the lower cranial nerves, by bony elements of the craniocervical junction, and by the vertebrobasilar vessels. Currently, the open approach of choice is a lateral extension of the posterior midline approach including far lateral, and extreme lateral routes. However, the transoraltranspharyngeal approach remains the treatment of choice in cases of diseases affecting the craniocervical junction. For very selective cases, the endoscopic endonasal route to this region is another option. We present a case of a ventral FM meningioma treated exclusively with the endoscopic endonasal approach.

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 Endoscopic-Assisted Resection of Anterior Foramen Magnum Meningiomas through a Midline Suboccipital Subtonsillar Approach

2021 ◽  
Author(s):  
Florian Roser ◽  
Luigi Rigante
Keyword(s):  
Anterior Part ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Anterior Portion ◽  
Suboccipital Craniotomy ◽  
Dural Attachment ◽  
Surgical Corridor ◽  
Lower Cranial Nerves ◽  
Brain Retraction

Abstract Objective This study was aimed to demonstrate the resection of anterior foramen magnum meningiomas through an endoscopic-assisted posterior midline suboccipital subtonsillar approach. Design This study was designed with illustration of the surgical steps and safety of this approach. Setting Evidence of cerebrospinal fluid (CSF) cleft between the tumor and brainstem on MRI was studied (Fig. 1A and B). Preoperative tracheotomy was considered in cases of preoperative dysphagia to prevent any further neurological deterioration due to the bilateral access through the lower cranial nerves corridors. Semisitting position with extensive electrophysiological neuromonitoring and transesophageal echocardiogram was adopted. A standard midline incision with bilateral suboccipital craniotomy and C1-laminotomy was performed (Fig. 2A). After partial resection and elevation of the tonsils, tumor was debulked unilaterally around the lower cranial nerves and the vertebral artery, devascularized from the clival dura and then dissected from the brainstem (Fig. 2B, C). Endoscopic-assisted removal of its anterior portion followed. The same procedure was repeated from the opposite site for the contralateral portion, before approaching the purely anterior part with endoscope assistance (Fig. 2D). Participants Four consecutive patients were included in the study. Main Outcome Measures Grade of tumor resection and outcome (mRS) were primary measurement of this study. Results Clinical outcome and grade of resection are comparable to other series of patient treated with other foramen magnum approaches (Fig. 1C and D). Conclusion Anterior foramen magnum meningiomas can be safely removed through this relatively faster midline suboccipital approach with bilateral exposure of lower cranial nerves (CNs) and vertebral arteries and lower approach-related morbidity (no condyle drilling). The surgical corridor is created by the tumor during debulking reducing need for brain retraction and the removal of the anterior dural attachment coagulated under the microscope is verified and completed endoscopically with pituitary curettes (Simpson's grade II) (Fig. 1C and D).The link to the video can be found at: https://youtu.be/9eACAJVwQBs.

scholarly journals Endoscopic endonasal approach for clipping of a PICA aneurysm

2020 ◽  
Vol 2 (2) ◽  
pp. V14
Author(s):  
Ezequiel Goldschmidt ◽  
Philippe Lavigne ◽  
Carl Snyderman ◽  
Paul A. Gardner
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Neurological Deficits ◽  
Csf Leak ◽  
Open Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Posthemorrhagic Hydrocephalus ◽  
Cerebellar Artery ◽  
Lower Cranial Nerves

This video depicts the case of a 59-year-old woman that presented to the emergency department with the worst headache of her life. CT showed subarachnoid hemorrhage and digital subtraction angiogram demonstrated a right-side posterior inferior cerebellar artery (PICA) aneurysm. Given the medial and ventral position of the aneurysm, deep to the lower cranial nerves, which obviated distal control from an open approach, and the absence of an endovascular option able to reliably preserve the PICA, an endonasal approach was offered. A far medial approach was performed, and the aneurysm was successfully clipped. The patient developed a postoperative CSF leak with persistent posthemorrhagic hydrocephalus treated with reexploration and an eventual ventriculoperitoneal shunt. The patient was discharged without neurological deficits.The video can be found here: https://youtu.be/_9hsM2CaMow.

The Front Door to Meckel's Cave: An Anteromedial Corridor via Expanded Endoscopic Endonasal Approach—Technical Considerations and Clinical Series

2009 ◽  
Vol 64 (suppl_1) ◽  
pp. ONS71-ONS83 ◽  
Author(s):  
Amin B. Kassam ◽  
Daniel M. Prevedello ◽  
Ricardo L. Carrau ◽  
Carl H. Snyderman ◽  
Paul Gardner ◽  
...  
Keyword(s):  
Medical Center ◽  
Cranial Nerves ◽  
Abducens Nerve ◽  
Direct Access ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Meckel’S Cave ◽  
Endoscopic Endonasal ◽  
Clinical Series ◽  
Meckel's Cave

Abstract Objective: Tumors within Meckel's cave are challenging and often require complex approaches. In this report, an expanded endoscopic endonasal approach is reported as a substitute for or complement to other surgical options for the treatment of various tumors within this region. Methods: A database of more than 900 patients who underwent the expanded endoscopic endonasal approach at the University of Pittsburgh Medical Center from 1998 to March of 2008 were reviewed. From these, only patients who had an endoscopic endonasal approach to Meckel's cave were considered. The technique uses the maxillary sinus and the pterygopalatine fossa as part of the working corridor. Infraorbital/V2 and the vidian neurovascular bundles are used as surgical landmarks. The quadrangular space is opened, which is bound by the internal carotid artery medially and inferiorly, V2 laterally, and the abducens nerve superiorly. This offers direct access to the anteroinferomedial segment of Meckel's cave, which can be extended through the petrous bone to reach the cerebellopontine angle. Results: Forty patients underwent an endoscopic endonasal approach to Meckel's cave. The most frequent abnormalities encountered were adenoid cystic carcinoma, meningioma, and schwannomas. Meckel's cave and surrounding structures were accessed adequately in all patients. Five patients developed a new facial numbness in at least 1 segment of the trigeminal nerve, but the deficit was permanent in only 2. Two patients had a transient Vlth cranial nerve palsy. Nine patients (30%) showed improvement of preoperative deficits on Cranial Nerves III to VI. Conclusion: In selected patients, the expanded endoscopic endonasal approach to the quadrangular space provides adequate exposure of Meckel's cave and its vicinity, with low morbidity.

Endoscopic Endonasal Transclival Transcondylar Approach for Foramen Magnum Meningiomas

2015 ◽  
Vol 12 (2) ◽  
pp. 153-162 ◽  
Author(s):  
Wei-Hsin Wang ◽  
Kumar Abhinav ◽  
Eric Wang ◽  
Carl Snyderman ◽  
Paul A Gardner ◽  
...  
Keyword(s):  
Odontoid Process ◽  
Human Head ◽  
Foramen Magnum ◽  
Surgical Anatomy ◽  
Occipital Condyle ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal ◽  
Medial Condyle ◽  
Anterior Arch ◽  
Surgical Corridor

Abstract BACKGROUND The endoscopic endonasal approach provides a direct route to ventral foramen magnum (FM) lesions like meningiomas, which are difficult to access. Endonasal access at the FM is limited laterally by the occipital condyles and inferiorly by the C1 anterior arch and the odontoid process, which may need partial resection. OBJECTIVE We investigated the surgical anatomy and technical nuances for endonasally increasing the surgical corridor at the FM region both laterally and inferiorly. Unique to our report, we quantified the amount of required medial condyle resection to obtain exposure of the lateral aspects of the FM. METHODS Five fresh human head silicone-injected specimens underwent endonasal inferior transclival, transcondylar approaches. The lateral limit of medial condyle resection was defined using a vertical line extending inferiorly from foramen lacerum and its intersection with the occipital condyle. The condylectomy was limited posteriorly by the cortical bone surrounding the hypoglossal canal. The volume of the resected condyle (cubic centimeters) for 10 sides was measured using the pre- and postdissection computed tomography-volumetric analysis. RESULTS The mean percentage condylar volume resected during a unilateral medial condylectomy was 18% (9.7%-28.3%). The surgical corridor was extended inferiorly in all specimens without violating the transverse ligament by drilling the superior aspects of C1 anterior arch and the exposed odontoid tip. These operative nuances were successfully applied in the operating room. CONCLUSION Anatomical landmarks can reliably guide an endonasal anteromedial condyle resection. Minimal condyle resection is required to widen lateral access at the FM, which minimizes the risk of craniocervical instability.

Anatomic comparison of the endonasal and transpetrosal approaches for interpeduncular fossa access

2014 ◽  
Vol 37 (4) ◽  
pp. E12 ◽  
Author(s):  
Kenichi Oyama ◽  
Daniel M. Prevedello ◽  
Leo F. S. Ditzel Filho ◽  
Jun Muto ◽  
Ramazan Gun ◽  
...  
Keyword(s):  
Direct Access ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Interpeduncular Cistern ◽  
Fresh Cadaver ◽  
Surgical Options ◽  
Surgical Corridor ◽  
Retrochiasmatic Area ◽  
Neurovascular Structures

Object The interpeduncular cistern, including the retrochiasmatic area, is one of the most challenging regions to approach surgically. Various conventional approaches to this region have been described; however, only the endoscopic endonasal approach via the dorsum sellae and the transpetrosal approach provide ideal exposure with a caudal-cranial view. The authors compared these 2 approaches to clarify their limitations and intrinsic advantages for access to the interpeduncular cistern Methods Four fresh cadaver heads were studied. An endoscopic endonasal approach via the dorsum sellae with pituitary transposition was performed to expose the interpeduncular cistern. A transpetrosal approach was performed bilaterally, combining a retrolabyrinthine presigmoid and a subtemporal transtentorium approach. Water balloons were used to simulate space-occupying lesions. “Water balloon tumors” (WBTs), inflated to 2 different volumes (0.5 and 1.0 ml), were placed in the interpeduncular cistern to compare visualization using the 2 approaches. The distances between cranial nerve (CN) III and the posterior communicating artery (PCoA) and between CN III and the edge of the tentorium were measured through a transpetrosal approach to determine the width of surgical corridors using 0- to 6-ml WBTs in the interpeduncular cistern (n = 8). Results Both approaches provided adequate exposure of the interpeduncular cistern. The endoscopic endonasal approach yielded a good visualization of both CN III and the PCoA when a WBT was in the interpeduncular cistern. Visualization of the contralateral anatomical structures was impaired in the transpetrosal approach. The surgical corridor to the interpeduncular cistern via the transpetrosal approach was narrow when the WBT volume was small, but its width increased as the WBT volume increased. There was a statistically significant increase in the maximum distance between CN III and the PCoA (p = 0.047) and between CN III and the tentorium (p = 0.029) when the WBT volume was 6 ml. Conclusions Both approaches are valid surgical options for retrochiasmatic lesions such as craniopharyngiomas. The endoscopic endonasal approach via the dorsum sellae provides a direct and wide exposure of the interpeduncular cistern with negligible neurovascular manipulation. The transpetrosal approach also allows direct access to the interpeduncular cistern without pituitary manipulation; however, the surgical corridor is narrow due to the surrounding neurovascular structures and affords poor contralateral visibility. Conversely, in the presence of large or giant tumors in the interpeduncular cistern, which widen the spaces between neurovascular structures, the transpetrosal approach becomes a superior route, whereas the endoscopic endonasal approach may provide limited freedom of movement in the lateral extension.

scholarly journals Value of Free-Run Electromyographic Monitoring of Lower Cranial Nerves in Endoscopic Endonasal Approach to Skull Base Surgeries

2012 ◽  
Vol 73 (04) ◽  
pp. 236-244 ◽  
Author(s):  
Parthasarathy Thirumala ◽  
Santhosh Mohanraj ◽  
Miguel Habeych ◽  
Kelley Wichman ◽  
Yue-Fang Chang ◽  
...  
Keyword(s):  
Skull Base ◽  
Cranial Nerves ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Lower Cranial Nerves

scholarly journals Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations

2005 ◽  
Vol 19 (1) ◽  
pp. 1-14 ◽  
Author(s):  
Luigi M. Cavallo ◽  
Andrea Messina ◽  
Paolo Cappabianca ◽  
Felice Esposito ◽  
Enrico de Divitiis ◽  
...  
Keyword(s):  
Skull Base ◽  
Dura Mater ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Lateral Direction ◽  
Endoscopic Endonasal ◽  
Fresh Cadaver ◽  
Csf Leakage

Object The midline skull base is an anatomical area that extends from the anterior limit of the cranial fossa down to the anterior border of the foramen magnum. Resection of lesions involving this area requires a variety of innovative skull base approaches. These include anterior, anterolateral, and posterolateral routes, performed either alone or in combination, and resection via these routes often requires extensive neurovascular manipulation. The goals in this study were to define the application of the endoscopic endonasal approach and to become more familiar with the views and skills associated with the technique by using cadaveric specimens. Methods To assess the feasibility of the endonasal route for the surgical management of lesions in the midline skull base, five fresh cadaver heads injected with colored latex were dissected using a modified endoscopic endonasal approach. Full access to the skull base and the cisternal space around it is possible with this route. From the crista galli to the spinomedullary junction, with incision of the dura mater, a complete visualization of the carotid and vertebrobasilar arterial systems and of all 12 of the cranial nerves is obtainable. Conclusions The major potential advantage of the endoscopic endonasal approach to the skull base is that it provides a direct anatomical route to the lesion without traversing any major neurovascular structures, obviating brain retraction. Many tumors grow in a medial-to-lateral direction, displacing structures laterally as they expand, creating natural corridors for their resection via an anteromedial approach. Potential disadvantages of this procedure include the relatively restricted working space and the danger of an inadequate dural repair with cerebrospinal fluid (CSF) leakage and potential for meningitis resulting. These approaches often require a large opening of the dura mater over the tuberculum sellae and posterior planum sphenoidale, or retroclival space. In addition, they typically involve large intraoperative CSF leaks, which necessitate precise and effective dural closure.

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