Transapical extension in difficult cerebellopontine angle tumours: preliminary report

2003 ◽  
Vol 117 (10) ◽  
pp. 788-792 ◽  
Author(s):  
Mario Sanna ◽  
Manoj Agarwal ◽  
Yogesh Jain ◽  
Alessandra Russo ◽  
Abdel Kader Taibah
Keyword(s):  
Vestibular Schwannoma ◽  
Cerebellopontine Angle ◽  
Cranial Nerves ◽  
Internal Auditory Canal ◽  
Petrous Bone ◽  
Vestibular Schwannomas ◽  
Type I ◽  
Posterior Surface ◽  
Prepontine Cistern ◽  
Anterior Extension

Difficult cerebellopontine angle (CPA) tumours namely large/giant vestibular schwannomas, vestibular schwannomas with a significant anterior extension and meningiomas of the posterior surface of the petrous bone extending anterior to the internal auditory canal (IAC) have always posed a problem for the otoneurosurgeon. Modifications of the enlarged translabyrinthine approach (ETLA) specifically aimed at dealing with these tumours are not reported. The aim of this paper is to introduce the transapical extension of ETLA which involves increased circumferential drilling around the IAC beyond 270°C. The extension allows enhanced surgical control over the tumour as well as the anterior aspect of the CPA including the prepontine cistern, the Vth and VIth cranial nerves. The extension is further classified into Type I and II depending upon the extent of drilling. Type I extension entails drilling around the IAC for 300–320° and is indicated for large/giant vestibular schwannomas (large vestibular schwannoma extrameatal diameter 3–3.9 cm, giant vestibular schwannoma extrameatal diameter [ges ]4 cm) and vestibular schwannomas with significant anterior extension. Type II extension involves complete drilling around the canal for 360° and is indicated for meningiomas of the posterior surface of the petrous bone extending anterior to the IAC.

Spreading of the vestibular schwannoma into porus acusticus internus. Endoscopic removal possibilities

2018 ◽  
pp. 40-44
Author(s):  
Orest Palamar ◽  
Andriy Huk ◽  
Dmytro Okonskyi ◽  
Ruslan Aksyonov ◽  
Dmytro Teslenko
Keyword(s):  
Vestibular Schwannoma ◽  
Internal Auditory Canal ◽  
Residual Tumor ◽  
Endoscopic Technique ◽  
Vestibular Schwannomas ◽  
Endoscopic Removal ◽  
Tumor Removal ◽  
Tumor Spread ◽  
Microsurgical Technique ◽  
Tumor Visualization

Aim: To investigate the features of the vestibular schwannoma spread into the internal auditory canal and the possibilities of endoscopic removal. Objectives: To improve tumor visualization in the internal auditory canal; to create a sufficient view angle for tumor removal during endoscopic opening of the internal auditory canal. Materials and methods: The results of surgical treatment of 20 patients with vestibular schwannomas in which the tumor spread to the internal auditory canal were analyzed. Microsurgical tumor removal was performed in 14 cases; Fully endoscopic removal of vestibular schwannomas was performed in 6 cases. The internal auditory canal opening was performed in 14 cases using microsurgical technique and in 6 cases with fully the endoscopic technique. Results: Gross total removal was achieved in 18 cases, subtotal removal in 2 cases. The tumor spread into the internal auditory canal was removed in all cases (100%). Opening the internal auditory canal using the endoscopic technique allows to increase the view angle (up to 20%) and to visualize along the axis of canal. Conclusions: 1) Endoscopic assistance technique allows to improve residual tumor visualization much more better then microsurgical technique; 2) Internal auditory canal opening using endoscopic technique is much more effective than the microsurgical technique (trepanning depth is larger); 3) Endoscopic methods for the internal auditory canal opening allows to increase canal angle view up to 20% (comparing to the microsurgical view).

Meningiomas Of the Internal Auditory Canal

Neurosurgery ◽  
2004 ◽  
Vol 55 (1) ◽  
pp. 119-128 ◽  
Author(s):  
Makoto Nakamura ◽  
Florian Roser ◽  
Sharham Mirzai ◽  
Cordula Matthies ◽  
Peter Vorkapic ◽  
...  
Keyword(s):  
Cerebellopontine Angle ◽  
Clinical Symptoms ◽  
Management Strategies ◽  
Internal Auditory Canal ◽  
Signs And Symptoms ◽  
Vestibular Schwannomas ◽  
Additional Patient ◽  
Surgical Removal ◽  
Neurosurgical Department ◽  
Vestibulocochlear Nerve

Abstract OBJECTIVE: Meningiomas arising primarily within the internal auditory canal (IAC) are notably rare. By far the most common tumors that are encountered in this region are neuromas. We report a series of eight patients with meningiomas of the IAC, analyzing the clinical presentations, surgical management strategies, and clinical outcomes. METHODS: The charts of the patients, including histories and audiograms, imaging studies, surgical records, discharge letters, histological records, and follow-up records, were reviewed. RESULTS: One thousand eight hundred meningiomas were operated on between 1978 and 2002 at the Neurosurgical Department of Nordstadt Hospital. Among them, there were 421 cerebellopontine angle meningiomas; 7 of these (1.7% of cerebellopontine angle meningiomas) were limited to the IAC. One additional patient underwent surgery at the Neurosurgical Department of the International Neuroscience Institute, where a total of 21 cerebellopontine angle meningiomas were treated surgically from 2001 to 2003. As a comparison, the incidence of intrameatal vestibular schwannomas during the same period, 1978 to 2002, was 168 of 2400 (7%). There were five women and three men, and the mean age was 49.3 years (range, 27–59 yr). Most patients had signs and symptoms of vestibulocochlear nerve disturbance at presentation. One patient had sought treatment previously for total hearing loss before surgery. No patient had a facial paresis at presentation. The neuroradiological workup revealed a homogeneously contrast-enhancing tumor on magnetic resonance imaging in all patients with hypointense or isointense signal intensity on T1- and T2-weighted images. Some intrameatal meningiomas showed broad attachment, and some showed a dural tail at the porus. In all patients, the tumor was removed through the lateral suboccipital retrosigmoid approach with drilling of the posterior wall of the IAC. Total removal was achieved in all cases. Severe infiltration of the facial and vestibulocochlear nerve was encountered in two patients. There was no operative mortality. Hearing was preserved in five of seven patients; one patient was deaf before surgery. Postoperative facial weakness was encountered temporarily in one patient. CONCLUSION: Although intrameatal meningiomas are quite rare, they must be considered in the differential diagnosis of intrameatal mass lesions. The clinical symptoms are very similar to those of vestibular schwannomas. A radiological differentiation from vestibular schwannomas is not always possible. Surgical removal of intrameatal meningiomas should aim at wide excision, including involved dura and bone, to prevent recurrences. The variation in the anatomy of the faciocochlear nerve bundle in relation to the tumor has to be kept in mind, and preservation of these structures should be the goal in every case.

scholarly journals Sensitivity and Negative Predictive Value of Motor Evoked Potentials of the Facial Nerve

2021 ◽  
Author(s):  
Nicolas Bovo ◽  
Shahan Momjian ◽  
Renato Gondar ◽  
Philippe Bijlenga ◽  
Karl Schaller ◽  
...  
Keyword(s):  
Facial Nerve ◽  
Evoked Potentials ◽  
Negative Predictive Value ◽  
Patient Group ◽  
Vestibular Schwannoma ◽  
Predictive Value ◽  
Cerebellopontine Angle ◽  
Motor Evoked Potentials ◽  
Vestibular Schwannomas ◽  
Predictive Values

Abstract Objective The objective of this study was to determine the performance of the standard alarm criterion of motor evoked potentials (MEPs) of the facial nerve in surgeries performed for resections of vestibular schwannomas or of other lesions of the cerebellopontine angle. Methods This retrospective study included 33 patients (16 with vestibular schwannomas and 17 with other lesions) who underwent the resection surgery with transcranial MEPs of the facial nerve. A reproducible 50% decrease in MEP amplitude, resistant to a 10% increase in stimulation intensity, was applied as the alarm criterion during surgery. Facial muscular function was clinically evaluated with the House–Brackmann score (HBS), pre- and postsurgery at 3 months. Results In the patient group with vestibular schwannoma, postoperatively, the highest sensitivity and negative predictive values were found for a 30% decrease in MEP amplitude, that is, a criterion stricter than the 50% decrease in MEP amplitude criterion, prone to trigger more warnings, used intraoperatively. With this new criterion, the sensitivity would be 88.9% and the negative predictive value would be 85.7%. In the patient group with other lesions of the cerebellopontine angle, the highest sensitivity and negative predictive values were found equally for 50, 60, or 70% decrease in MEP amplitude. With these criteria, the sensitivities and the negative predictive values would be 100.0%. Conclusion Different alarm criteria were found for surgeries for vestibular schwannomas and for other lesions of the cerebellopontine angle. The study consolidates the stricter alarm criterion, that is, a criterion prone to trigger early warnings, as found previously by others for vestibular schwannoma surgeries (30% decrease in MEP amplitude).

scholarly journals Trigeminal Nerve Schwannoma of the Cerebellopontine Angle

2018 ◽  
Vol 79 (S 05) ◽  
pp. S389-S390
Author(s):  
Maria Peris-Celda ◽  
Christopher Graffeo ◽  
Avital Perry ◽  
Lucas Carlstrom ◽  
Michael Link
Keyword(s):  
Trigeminal Nerve ◽  
Cerebellopontine Angle ◽  
Incidental Finding ◽  
Cranial Nerves ◽  
Internal Auditory Canal ◽  
Clinical History ◽  
Sensory Loss ◽  
Meckel’S Cave ◽  
Neurologic Deficits ◽  
Meckel's Cave

Introduction Large and even moderate sized, extra-axial cerebellopontine angle (CPA) tumors may fill this restricted space and distort the regional anatomy. It may be difficult to determine even with high resolution magnetic resonance imaging (MRI) if the tumor is dural-based, or what the nerve of origin is if a schwannoma. While clinical history and exam are helpful, they are not unequivocal, particularly since many patients present with a myriad of symptoms, or conversely an incidental finding. We present an atypical appearing, asymptomatic CPA tumor, ultimately identified at surgery to be a trigeminal schwannoma. Case History A 40-year-old man presented with new-onset seizure. MRI identified an incidental heterogeneously contrast-enhancing CPA lesion (Fig. 1A–D). The tumor was centered on the internal auditory canal (IAC) with no tumor extension into Meckel's cave, IAC or jugular foramen. Audiometry demonstrated 10db of relative left-sided hearing loss with 100% word recognition. Physical examination was negative for focal neurologic deficits. A retrosigmoid craniotomy was performed and an extra-axial, yellow-hued mass was encountered and resected, which was ultimately confirmed to originate from the trigeminal nerve (Video 1). Gross total resection was achieved, and the patient recovered from surgery with partial ipsilateral trigeminal sensory loss and no other new neurologic deficits. Conclusion Pure CPA trigeminal schwannomas are rare, but should be considered in the differential for enhancing CPA lesions. Although, Meckel's cave involvement is frequently observed, it is not universal, and pure CPA schwannomas of all cranial nerves IV–XII have been reported in the literature.The link to the video can be found at: https://youtu.be/AlodYCu70F8.

scholarly journals Metastatic Extrapulmonary Small Cell Carcinoma to the Cerebellopontine Angle: A Case Report and Review of the Literature

2015 ◽  
Vol 2015 ◽  
pp. 1-6
Author(s):  
Debebe Theodros ◽  
C. Rory Goodwin ◽  
Genevieve M. Crane ◽  
Jason Liauw ◽  
Lawrence Kleinberg ◽  
...  
Keyword(s):  
Cell Carcinoma ◽  
Surgical Resection ◽  
Small Cell Carcinoma ◽  
Vestibular Schwannoma ◽  
Primary Tumor ◽  
Cerebellopontine Angle ◽  
Internal Auditory Canal ◽  
Small Cell ◽  
Poorly Differentiated ◽  
Small Intestinal

Extrapulmonary small cell carcinomas (EPSCC) are rare malignancies with poor patient prognoses. We present the case of a 63-year-old male who underwent surgical resection of a poorly differentiated small cell carcinoma, likely from a small intestinal primary tumor that metastasized to the cerebellopontine angle (CPA). A 63-year-old male presented with mild left facial paralysis, hearing loss, and balance instability. MRI revealed a 15 mm mass in the left CPA involving the internal auditory canal consistent with a vestibular schwannoma. Preoperative MRI eight weeks later demonstrated marked enlargement to 35 mm. The patient underwent a suboccipital craniectomy and the mass was grossly different visually and in consistency from a standard vestibular schwannoma. The final pathology revealed a poorly differentiated small cell carcinoma. Postoperative PET scan identified avid uptake in the small intestine suggestive of either a small intestinal primary tumor or additional metastatic disease. The patient underwent whole brain radiation therapy and chemotherapy and at last follow-up demonstrated improvement in his symptoms. Surgical resection and radiotherapy are potential treatment options to improve survival in patients diagnosed with NET brain metastases. We present the first documented case of skull base metastasis of a poorly differentiated small cell carcinoma involving the CPA.

Posterior petrous meningiomas: 82 cases

2005 ◽  
Vol 102 (2) ◽  
pp. 284-289 ◽  
Author(s):  
Zhe Bao Wu ◽  
Chun Jiang Yu ◽  
Shu Sen Guan
Keyword(s):  
Facial Nerve ◽  
Clinical Manifestations ◽  
Petrous Bone ◽  
Type I ◽  
Type Ii ◽  
Posterior Surface ◽  
Total Resection ◽  
Content Type ◽  
Functional Preservation ◽  
Fine Print

Object. The aim of this study was to discuss posterior petrous meningiomas—their classification, clinical manifestations, surgical treatments, and patient outcomes. Methods. A retrospective analysis was performed in 82 patients with posterior petrous meningiomas for microsurgery. According to the anatomical relationship with the posterior surface of the petrous bone and with special reference to the internal auditory canal (IAC), posterior petrous meningiomas were classified into three types: Type I, located laterally to the IAC (28 cases); Type II, located medially to the IAC, which might extend to the cavernous sinus and clivus (32 cases); and Type III, extensively attached to the posterior surface of the petrous bone, which might envelop the seventh and eighth cranial nerves (22 cases). Sixty-eight (83%) of 82 cases involved total resection. The rate of anatomical preservation of facial nerve was 97.5%, whereas the functional preservation rate was 81%. The rate of hearing preservation was 67%. All Type I tumors were completely resected, and the rate of anatomical preservation of facial nerve was 100% and functional preservation was 93%. Regarding Type II lesions, 75% of 32 cases involved total resection; the rate of anatomical preservation of facial nerve was 97% and functional preservation was 75%. For Type III lesions, 73% of 22 cases were totally resected. The rate of anatomical preservation of facial nerve in patients with this tumor type was 95%, whereas functional preservation was 73%. Conclusions. Clinical manifestations and surgical prognoses are different among the various types of posterior petrous meningiomas. It is more difficult for Types II and III tumors to be resected radically than Type I lesions, and postoperative functional outcomes are significantly worse accordingly. The primary principles in dealing with this disease entity include preservation of vital vascular and central nervous system structures and total resection of the tumor as much as possible.

High Jugular Bulb: Implications for Posterior Fossa Neurotologic and Cranial Base Surgery

1993 ◽  
Vol 102 (2) ◽  
pp. 100-107 ◽  
Author(s):  
Steven D. Rauch ◽  
Wen-Zhuang Xv ◽  
Joseph B. Nadol
Keyword(s):  
Temporal Bone ◽  
Posterior Fossa ◽  
Cerebellopontine Angle ◽  
Internal Auditory Canal ◽  
Petrous Bone ◽  
Jugular Bulb ◽  
Variable Position ◽  
High Jugular Bulb ◽  
Cranial Base Surgery ◽  
Bone Exposure

The suboccipital-retrosigmoid approach to the internal auditory canal and cerebellopontine angle is being used with increasing frequency for neurotologic surgery, including vestibular nerve section and resection of acoustic neuroma. It offers wide exposure of the cerebellopontine angle and the cranial nerve VII—VIII complex as it courses from the brain stem to the temporal bone. Exposure of the internal auditory canal can be achieved by removing its posterior bony wall. Safe utilization of this approach requires familiarity with the variable position of structures within the petrous bone, including the lateral venous sinus and jugular bulb. We report here a case in which bleeding resulted from injury to a high jugular bulb during surgical exposure of the internal auditory canal via the suboccipital route and discuss the regional anatomy of the jugular bulb based on study of 378 consecutive temporal bone specimens from the collection of the Massachusetts Eye and Ear Infirmary. High jugular bulb was defined as encroachment of the dome of the bulb within 2 mm of the floor of the internal auditory canal. Forty-six percent of scoreable specimens met this criterion. However, when donors less than 6 years of age were excluded, a high jugular bulb was identified in 63% of specimens. Relevance to neurotologic surgery of the posterior fossa is presented.

scholarly journals Internal Auditory Canal Reconstruction After Vestibular Schwannomas Removal Through Retrosigmoid-Transmeatal Approach

2018 ◽  
Vol 26 (3) ◽  
pp. 237-241
Author(s):  
Ricardo Ramina ◽  
Gustavo Simiano Jung ◽  
Erasmo Barros Da Silva Jr ◽  
Guilherme José Agnoletto ◽  
Luis Fernando Moura Da Silva Jr ◽  
...  
Keyword(s):  
Cranial Nerves ◽  
Internal Auditory Canal ◽  
Jugular Foramen ◽  
Vestibular Schwannomas ◽  
Fat Tissue ◽  
Resonance Imaging ◽  
Tumor Removal ◽  
Postoperative Mri ◽  
Csf Leakage ◽  
Magnetic Resonance Imaging Mri

Objectives: To present a technique of internal auditory canal (IAC) reconstruction using a pediculated dural flap, after removal of vestibular schwannomas through the retrosigmoid craniotomy. Methods: From a series of 213 patients with vestibular schwannomas operated between January 2008 and March 2016 through the retrosigmoid-transmeatal approach, 183 underwent reconstruction of the internal auditory canal with a pediculated dural flap. The IAC was drilled towards the fundus preserving the labyrinthine structures. The dura mater over the IAC was dissected from the bone, remaining pediculated at the entrance of the jugular foramen. This dural flap was used to cover the cranial nerves inside the IAC after tumor removal. Opened mastoid cells and the IAC were closed with muscle or fat grafts and fibrin glue. Results: Reconstruction of the IAC using the described technique was possible in in 183 cases. Fifteen patients (6.8%) developed postoperative cerebrospinal fluid (CSF) leakage and seven patients required reoperation (3.2%) to close the fistulae. Postoperative magnetic resonance imaging (MRI) examinations showed the presence of CSF within the IAC around the preserved cranial nerves. Conclusions: This technique of IAC reconstruction after surgical resection of vestibular schwannomas may avoid scar and adhesion of muscle or fat tissue with preserved cranial nerves, allowing CSF enter inside the IAC. It may help to identify tumor remnants and/or recurrences in postoperative MRI examinations. Comparative studies are needed to evaluate if this technique improves postoperative hearing and facial nerve outcomes.

scholarly journals An aberrant venous channel mimicking the perilabyrinthine cells in the petrous bone of a patient with vestibular schwannoma: illustrative case

2021 ◽  
Vol 2 (18) ◽  
Author(s):  
Masato Ito ◽  
Yoshinori Higuchi ◽  
Kentaro Horiguchi ◽  
Shigeki Nakano ◽  
Shinichi Origuchi ◽  
...  
Keyword(s):  
Vestibular Schwannoma ◽  
Internal Auditory Canal ◽  
Posterior Wall ◽  
Anatomical Variations ◽  
Petrous Bone ◽  
Bone Defects ◽  
Jugular Bulb ◽  
Illustrative Case ◽  
Computed Tomographic ◽  
Major Vein

BACKGROUND Anatomical variations, such as high jugular bulbs and air cell development in the petrosal bone, should be evaluated before surgery. Most bone defects in the internal auditory canal (IAC) posterior wall are observed in the perilabyrinthine cells. An aberrant vascular structure passing through the petrous bone is rare. OBSERVATIONS A 48-year-old man presented with a right ear hearing disturbance. Magnetic resonance imaging revealed a 23-mm contrast-enhancing mass in the right cerebellopontine angle extending into the IAC, consistent with a right vestibular schwannoma. Preoperative bone window computed tomographic scans showed bone defects in the IAC posterior wall, which ran farther posteroinferiorly in the petrous bone, reaching the medial part of the jugular bulb. The tumor was accessed via a lateral suboccipital approach. There was no other major vein in the cerebellomedullary cistern, except for the vein running from the brain stem to the IAC posterior wall. To avoid complications due to venous congestion, the authors did not drill out the IAC posterior wall or remove the tumor in the IAC. LESSONS Several aberrant veins in the petrous bone are primitive head sinus remnants. Although rare, their surgical implication is critical in patients with vestibular schwannomas.

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