Transmastoid Retrosigmoid Approach to the Cerebellopontine Angle: Surgical Technique

2012 ◽  
Vol 73 (suppl_1) ◽  
pp. ons16-ons23 ◽  
Author(s):  
Mohammad Abolfotoh ◽  
Ian F. Dunn ◽  
Ossama Al-Mefty
Keyword(s):  
Surgical Technique ◽  
Cerebellopontine Angle ◽  
Traditional Approach ◽  
Senior Author ◽  
Retrosigmoid Approach ◽  
Mastoid Process ◽  
Suboccipital Craniotomy ◽  
Cerebellar Retraction ◽  
The Mean ◽  
Working Distance

Abstract BACKGROUND: The traditional suboccipital craniotomy in the retrosigmoid approach gives limited exposure to the cerebellopontine angle (CPA) structures and necessitates cerebellar retraction, whereas the addition of drilling of the mastoid process with reflection of venous sinuses offers wider exposure of the CPA and avoids cerebellar retraction. We describe the details of the surgical technique and provide radiological measurements substantiating the advantages of this approach. OBJECTIVE: To validate the usefulness of partial mastoidectomy in the retrosigmoid approach and to evaluate the complications of this maneuver. METHODS: Radiological CPA measurements on computed tomography bone window films were made on the last consecutive 20 patients who underwent CPA surgery via the transmastoid retrosigmoid approach. We measured the distance and angle of work by this approach and compared the measurements with those using the traditional retrosigmoid approach if that would have been used in each case. We also reviewed 432 patients from the records of the senior author to evaluate possible complications of this approach. RESULTS: The mean working distance for the transmastoid approach was 23.06 mm, whereas the working distance in the traditional approach was 46.44 mm. The mean increase in the angle of work after drilling of the mastoid was 25.39 degrees, and the simple average of increased distance in lateral exposure was 26.66 mm. CONCLUSION: The transmastoid retrosigmoid approach increases the exposure and gives better access to the CPA targets. This approach alleviates cerebellar retraction, facilitates surgery in the supine position, promotes the use of the endoscope, and is associated with negligible complications.

scholarly journals Microvascular Decompression for Geniculate Neuralgia through a Retrosigmoid Approach

2018 ◽  
Vol 80 (S 03) ◽  
pp. S322-S322
Author(s):  
Vincent N. Nguyen ◽  
Jaafar Basma ◽  
Jeffrey Sorenson ◽  
L. Madison Michael
Keyword(s):  
Microvascular Decompression ◽  
Cerebellopontine Angle ◽  
Cranial Nerves ◽  
Senior Author ◽  
Retrosigmoid Approach ◽  
Microsurgical Anatomy ◽  
Pain Syndromes ◽  
Large Vein ◽  
Microsurgical Techniques ◽  
Nervus Intermedius

Objectives To describe a retrosigmoid approach for the microvascular sectioning of the nervus intermedius and decompression of the 5th and 9th cranial nerves, with emphasis on microsurgical anatomy and technique. Design A retrosigmoid craniectomy is performed in the lateral decubitus position. The dura is opened and cerebrospinal fluid (CSF) is released from the cisterna magna and cerebellopontine cistern. Dynamic retraction without rigid retractors is performed. Subarachnoid dissection of the cerebellopontine angle exposes the 7th to 8th nerve complex. A neuromonitoring probe is used with careful inspection of the microsurgical anatomy to identify the facial nerve and the nervus intermedius as they enter the internal auditory meatus. The nervus intermedius is severed. A large vein coursing superiorly across cranial 9th nerve was coagulated and cut. A Teflon pledget is inserted between a small vessel and the 5th nerve. Photographs of the region are borrowed from Dr. Rhoton's laboratory to illustrate the microsurgical anatomy. Participants The senior author performed the surgery. The video was edited by Drs. V.N. and J.B. Outcome Measures Outcome was assessed by postoperative neurological function. Results The nervus intermedius was successfully cut and the 5th and 9th nerves were decompressed. The patient's pain resolved after surgery and at later follow-up. Conclusions Understanding the microsurgical anatomy of the cerebellopontine angle is necessary to identify the cranial nerves involved in facial pain syndromes. Subarachnoid dissection and meticulous microsurgical techniques are key elements for a successful microvascular decompression.The link to the video can be found at: https://youtu.be/pV5Wip7WusE.

Outcomes and complications of direct end-to-side facial-hypoglossal nerve anastomosis according to the modified May technique

2009 ◽  
Vol 110 (4) ◽  
pp. 786-791 ◽  
Author(s):  
Frederic Venail ◽  
Pascal Sabatier ◽  
Michel Mondain ◽  
François Segniarbieux ◽  
Christophe Leipp ◽  
...  
Keyword(s):  
Facial Palsy ◽  
Cerebellopontine Angle ◽  
Hypoglossal Nerve ◽  
Late Complications ◽  
Mastoid Process ◽  
Surgical Removal ◽  
Nerve Anastomosis ◽  
The Mean ◽  
Facial Synkinesis ◽  
Facial Function

Object The aim of this study was to address the efficiency and safety of direct end-to-side facial-hypoglossal nerve anastomosis for facial palsy rehabilitation. Methods The authors conducted a retrospective study of 12 consecutive procedures performed between December 2000 and February 2006. Facial palsies were caused by the surgical removal of tumors in the brainstem, cerebellopontine angle, or mastoid process. Direct end-to-side facial-hypoglossal anastomosis was performed in each case. Facial function (evaluated using the overall percentage of facial function and House-Brackmann scale grades), as well as tongue trophicity and mobility, were assessed at 6, 12, and 24 months after surgery. Postoperative early and late complications were systematically reviewed. Results The mean delay between tumoral and reparative surgery was 15.9 ± 4 months (median 11 months). Preoperatively, the mean percentage facial function score was 11.6 ± 1.7% (45% of patients with House-Brackmann Grade 5 facial palsy and 55% of patients with House-Brackmann Grade 6). Mean facial function scores increased to 19.3, 32.2, and 43.8% at 6, 12, and 24 months after surgery, respectively. Twenty-four months after surgery, 50% of cases had House-Brackmann Grade 3 facial palsy and 50% had Grade 4. A significantly better recovery at 24 months was observed postoperatively for neural lesions occurring in the mastoid or the brainstem compared with those in the cerebellopontine angle. Tongue hemiparesis was observed in 5 patients (41.7%), 2 of whom had tongue hypotrophy (16.7%). No patient complained of swallowing or speech disturbance. Facial synkinesis was noted in 1 patient (8.3%). Conclusions Facial recovery after direct end-to-side facial-hypoglossal nerve anastomosis is similar to results observed with end-to-end or end-to-side facial-hypoglossal nerve anastomosis with an interpositional graft. Tongue hypotrophy and palsy were observed in a small number of cases. This procedure allows one to minimize, although not fully prevent, facial synkinesis. The site of the neural lesion appears to be an important factor in the prognosis of recovery.

Reconstruction of unicoronal plagiocephaly with a hypercorrection surgical technique

2011 ◽  
Vol 31 (2) ◽  
pp. E4 ◽  
Author(s):  
John M. Mesa ◽  
Frank Fang ◽  
Karin M. Muraszko ◽  
Steven R. Buchman
Keyword(s):  
Surgical Technique ◽  
Surgical Repair ◽  
Surgical Techniques ◽  
Senior Author ◽  
Surgical Correction ◽  
Surgical Reconstruction ◽  
Calvarial Bone ◽  
The Mean ◽  
The Aesthetic

Object Successful surgical repair of unicoronal plagiocephaly remains a challenge for craniofacial surgeons. Many of the surgical techniques directed at correcting the stigmata associated with this craniofacial deformity (for example, ipsilateral supraorbital rim elevation [vertical dystopia], ipsilateral temporal constriction, C-shaped deformity of the face, and so on) are not long lasting and often result in deficient correction and the need for secondary revision surgery. The authors posit that the cause of this relapse was intrinsic deficiencies of the current surgical techniques. The aim of this study was to determine if correction of unilateral coronal plagiocephaly with a novel hypercorrection surgical technique could prevent the relapse of the characteristics associated with unicoronal plagiocephaly. Methods The authors performed a retrospective analysis of 40 consecutive patients who underwent surgical repair of unicoronal plagiocephaly at their institution between 1999 and 2009. In all cases, the senior author (S.R.B.) used a hypercorrection technique for surgical reconstruction. Hypercorrection consisted of significant overcorrection of the affected ipsilateral frontal and anterior temporal areas in the sagittal and coronal planes. Demographic, perioperative, and follow-up data were collected for comparison. The postsurgical appearance of the forehead was documented clinically and photographically and then evaluated and scored by 2 independent graders using the expanded Whitaker scoring system. A relapse was defined as a recurrence of preoperative features that required secondary surgical correction. Results The mean age of the patients at the time of the operation was 13 months (range 8–28 months). The mean follow-up duration was 57 months (range 3 months to 9.8 years). The postsurgical hypercorrection appearance persisted on average 6–8 months but gradually dissipated and normalized. No patients exhibited a relapse of unicoronal plagiocephalic characteristics that required surgical correction. In all cases the aesthetic results were excellent. Only 3 patients required reoperation for the management of persistent calvarial bone defects (2 cases) and removal of a symptomatic granuloma (1 case). Conclusions Our study demonstrates that patients who undergo unicoronal plagiocephaly repair with a hypercorrection surgical technique avoid long-term relapse. Our results suggest that the surgical technique used in the correction of unilateral coronal synostosis is strongly associated with the prevention of postsurgical relapse and that the use of this novel method decreases the need for surgical revision.

scholarly journals Surgery of vestibular schwannomas

2012 ◽  
Vol 01 (01) ◽  
pp. 009-013 ◽  
Author(s):  
Amir Samii ◽  
Venelin Gerganov ◽  
Madjid Samii
Keyword(s):  
Surgical Management ◽  
Operative Technique ◽  
Cerebellopontine Angle ◽  
Treatment Options ◽  
Senior Author ◽  
Retrosigmoid Approach ◽  
Vestibular Schwannomas ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
High Standards

Abstract Vestibular schwannomas (VS) are the most common tumors of the cerebellopontine angle (CPA). Their surgical management has reached high standards in the last decade. Treatment options for VS are microsurgical removal or Radiosurgery. The following three basic operative approaches are currently utilized: Retrosigmoid approach (RSA), translabyrinthine and middle fossa approach. The following article elaborates the operative technique by the senior author based on his vast experience of VS surgery formed over the last three decades; during which period he has operated more than 3500 of such patients

scholarly journals Extended Retrosigmoid Approach for the Resection of a Pontomedullary Junction Cavernous Malformation

2018 ◽  
Vol 79 (S 05) ◽  
pp. S418-S419
Author(s):  
Jaafar Basma ◽  
Vincent Nguyen ◽  
Jeffrey Sorenson ◽  
L. Michael
Keyword(s):  
Cerebellopontine Angle ◽  
Cavernous Malformation ◽  
Cranial Nerves ◽  
Extent Of Resection ◽  
Senior Author ◽  
Retrosigmoid Approach ◽  
Microsurgical Anatomy ◽  
Brainstem Cavernoma ◽  
Lateral Decubitus ◽  
Pontomedullary Junction

Objectives To describe an extended retrosigmoid approach for the resection of a cavernoma involving the ponto-medullary junction, with emphasis on the microsurgical anatomy and technique. Design A retrosigmoid craniotomy is performed in the lateral decubitus position and the sigmoid sinus exposed. After opening the dura, sutures are placed medial to the sinus to allow its gentle mobilization. Cerebrospinal fluid (CSF) is drained from the cisterna magna, and cerebellopontine cistern, and dynamic retraction is used over the cerebellum. Subarachnoid dissection of the cerebellopontine angle gives access to cranial nerves IX/X, VII/VIII, and VI. Inspection of the pontomedullary junction medial to the facial nerve reveals hemosiderin staining in that region. A small pial opening is made, exposing the hemorrhagic cavity. The cavernous malformation is then identified, dissected circumferentially, and resected. Photographs of the region are borrowed from Dr Rhoton's laboratory to illustrate the microsurgical anatomy. Participants The senior author performed the surgery. The video was edited by Drs. J.B. and V.N. Outcome Measures Outcome was assessed with extent of resection and postoperative neurological function. Results A gross total resection of the lesion was achieved. The patient did not develop any postoperative deficits. Conclusion Understanding the microsurgical anatomy of the cerebellopontine angle and meticulous microneurosurgical technique are necessary to achieve a complete resection of a brainstem cavernoma. The extended retrosigmoid approach provides an adequate corridor to the pontomedullary junction.The link to the video can be found at: https://youtu.be/FIKixWJT75w.

scholarly journals Extended Retrosigmoid Approach for Cerebellopontine Angle Meningiomas: Operative Technique and Results—A Series of 28 Patients

2018 ◽  
Vol 79 (05) ◽  
pp. 458-465 ◽  
Author(s):  
Celestino Pereira ◽  
Leonardo Welling ◽  
Mariangela Gonçalves ◽  
Nelci Zanon ◽  
Jose Lynch
Keyword(s):  
Operative Technique ◽  
Cerebellopontine Angle ◽  
Cranial Base ◽  
Sigmoid Sinus ◽  
Retrosigmoid Approach ◽  
Surgical Mortality ◽  
Total Removal ◽  
Surgical Strategies ◽  
The Mean

Background The purpose of this article is to describe our approach, surgical strategies, and results for resection of meningiomas located at cerebellopontine angle (CPA). Methods We retrospectively identified 28 patients with CPA meningiomas operated by the extended retrosigmoid approach. This approach incorporates a generous mastoidectomy and the sigmoid sinus exposure. Results The mean age was 33.8 years, with a follow-up of 12.5 years. Gross total removal (GTR) was achieved in 22 (78.5%) patients with low surgical mortality, acceptable morbidity, and recurrence rate of 7.1% (2 patients). Conclusion The extended retrosigmoid approach enhances the exposure of the CPA and posterior fossa cisterns and increases the surgical angle of maneuverability. This approach provides adequate access even to extensive CPA meningiomas, enabling, in most of cases, GTR to be safe and effective. The extended retrosigmoid approach used in this group of patients is an alternative to more extensive cranial base approaches.

The Extended Retrosigmoid Approach:An Alternative To Radical Cranial Base Approaches For Posterior Fossa Lesions

2006 ◽  
Vol 58 (suppl_4) ◽  
pp. ONS-208-ONS-214 ◽  
Author(s):  
Alfredo Quiñones-Hinojosa ◽  
Edward F. Chang ◽  
Michael T. Lawton
Keyword(s):  
Posterior Fossa ◽  
High Speed ◽  
Traditional Approach ◽  
Petrous Bone ◽  
Cranial Base ◽  
Senior Author ◽  
Sigmoid Sinus ◽  
Retrosigmoid Approach ◽  
Vascular Lesions ◽  
Cavernous Malformations

Abstract Objective: The extended retrosigmoid approach is presented as a simple and safe modification of the traditional retrosigmoid approach, with increased exposure resulting from a limited mastoidectomy and skeletonization of the sigmoid sinus. Methods: Patients with posterior fossa vascular lesions treated with the extended retrosigmoid approach between 1997 and 2003 were reviewed. A detailed description of the surgical approach, as well as case illustrations, is provided. We present a video narrated by the senior author in which a description of the technique is offered. Results: Thirty-eight patients underwent this approach to manage 40 lesions, including 15 dural arteriovenous fistulae, 9 arteriovenous malformations, 10 cavernous malformations, and 6 aneurysms. The extended retrosigmoid approach differs from the traditional approach with its C-shaped skin incision, posterior mastoidectomy, and extensive dissection of the sigmoid sinus, craniotomy rather than craniectomy, and anterior mobilization of the sinus with the dural flap. Conclusion: The application of the extended retrosigmoid approach to a series of complex lesions in the posterior fossa demonstrates its applicability as an alternative to radical cranial base approaches. The extended retrosigmoid approach requires a fundamental change in the management of the sigmoid sinus. The neurosurgeon must be familiar with petrous bone anatomy, experienced dissecting through bone using a high-speed drill, and comfortable working directly over a major venous sinus. The technical modifications of the extended retrosigmoid approach can be incorporated into the neurosurgical repertoire and will enhance exposure of the cerebellopontine angle and deep vascular structures, thereby minimizing the need for brain retraction and other transpetrous approaches.

Hemifacial Spasm: Endoscopic Vascular Decompression

1997 ◽  
Vol 117 (4) ◽  
pp. 308-314 ◽  
Author(s):  
J. Magnan ◽  
F. Caces ◽  
P. Locatelli ◽  
A. Chays
Keyword(s):  
Hemifacial Spasm ◽  
Marked Improvement ◽  
Cerebellopontine Angle ◽  
Posterior Inferior Cerebellar Artery ◽  
Endoscopic Examination ◽  
Anterior Inferior Cerebellar Artery ◽  
Cerebellar Artery ◽  
The Mean ◽  
Vascular Decompression

Sixty patients with primitive hemifacial spasm were treated by means of a minimally invasive retrosigmoid approach in which endoscopic and microsurgical procedures were combined. Intraoperative endoscopic examination of the cerebellopontine angle showed that for 56 of the patients vessel-nerve conflict was the cause of hemifacial spasm. The most common offending vessel was the posterior inferior cerebellar artery (39 patients), next was the vertebral artery (23 patients), and last was the anterior inferior cerebellar artery (16 patients). Nineteen of the patients had multiple offending vascular loops. In one patient, another cause of hemifacial spasm was an epidermoid tumor of the cerebellopontine angle. For three patients, it was not possible to determine the exact cause of the facial disorder. Follow-up information was reviewed for 54 of 60 patients; the mean follow-up period was 14 months. Fifty of the patients were in the vessel-nerve conflict group. Forty of the 50 were free of symptoms, and four had marked improvement. The overall success rate was 88%, and there was minimal morbidity (no facial palsy, two cases of severe hearing loss).

Translabyrinthine Approach for Acoustic Neuroma

Neurosurgery ◽  
2004 ◽  
Vol 54 (2) ◽  
pp. 391-396 ◽  
Author(s):  
John Diaz Day ◽  
Douglas A. Chen ◽  
Moises Arriaga
Keyword(s):  
Surgical Treatment ◽  
Acoustic Neuroma ◽  
Cerebellopontine Angle ◽  
Hearing Preservation ◽  
Retrosigmoid Approach ◽  
The Past ◽  
Translabyrinthine Approach ◽  
Acoustic Neuromas

Abstract THE TRANSLABYRINTHINE APPROACH has been popularized during the past 30 years for the surgical treatment of acoustic neuromas. It serves as an alternative to the retrosigmoid approach in patients when hearing preservation is not a primary consideration. Patients with a tumor of any size may be treated by the translabyrinthine approach. The corridor of access to the cerebellopontine angle is shifted anteriorly in contrast to the retrosigmoid approach, resulting in minimized retraction of the cerebellum. Successful use of the approach relies on a number of technical nuances that are outlined in this article.

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