scholarly journals Infraorbital nerve: a surgically relevant landmark for the pterygopalatine fossa, cavernous sinus, and anterolateral skull base in endoscopic transmaxillary approaches

2016 ◽  
Vol 125 (6) ◽  
pp. 1460-1468 ◽  
Author(s):  
Ali M. Elhadi ◽  
Hasan A. Zaidi ◽  
Kaan Yagmurlu ◽  
Shah Ahmed ◽  
Albert L. Rhoton ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Skull Base ◽  
Cavernous Sinus ◽  
Trigeminal Nerve ◽  
Infratemporal Fossa ◽  
Pterygopalatine Fossa ◽  
Infraorbital Nerve ◽  
External Carotid ◽  
Infraorbital Foramen ◽  
Foramen Rotundum

OBJECTIVE Endoscopic transmaxillary approaches (ETMAs) address pathology of the anterolateral skull base, including the cavernous sinus, pterygopalatine fossa, and infratemporal fossa. This anatomically complex region contains branches of the trigeminal nerve and external carotid artery and is in proximity to the internal carotid artery. The authors postulated, on the basis of intraoperative observations, that the infraorbital nerve (ION) is a useful surgical landmark for navigating this region; therefore, they studied the anatomy of the ION and its relationships to critical neurovascular structures and the maxillary nerve (V2) encountered in ETMAs. METHODS Endoscopic anatomical dissections were performed bilaterally in 5 silicone-injected, formalin-fixed cadaveric heads (10 sides). Endonasal transmaxillary and direct transmaxillary (Caldwell-Luc) approaches were performed, and anatomical correlations were analyzed and documented. Stereotactic imaging of each specimen was performed to correlate landmarks and enable precise measurement of each segment. RESULTS The ION was readily identified in the roof of the maxillary sinus at the beginning of the surgical procedure in all specimens. Anatomical dissections of the ION and the maxillary branch of the trigeminal nerve (V2) to the cavernous sinus suggested that the ION/V2 complex has 4 distinct segments that may have implications in endoscopic approaches: 1) Segment I, the cutaneous segment of the ION and its terminal branches (5–11 branches) to the face, distal to the infraorbital foramen; 2) Segment II, the orbitomaxillary segment of the ION within the infraorbital canal from the infraorbital foramen along the infraorbital groove (length 12 ± 3.2 mm); 3) Segment III, the pterygopalatine segment within the pterygopalatine fossa, which starts at the infraorbital groove to the foramen rotundum (13 ± 2.5 mm); and 4) Segment IV, the cavernous segment from the foramen rotundum to the trigeminal ganglion (15 ± 4.1 mm), which passes in the lateral wall of the cavernous sinus. The relationship of the ION/V2 complex to the contents of the cavernous sinus, carotid artery, and pterygopalatine fossa is described in the text. CONCLUSIONS The ION/V2 complex is an easily identifiable and potentially useful surgical landmark to the foramen rotundum, cavernous sinus, carotid artery, pterygopalatine fossa, and anterolateral skull base during ETMAs.

scholarly journals Gross Total Resection of a Recurrent in-and-around Cavernous Sinus Meningioma through a Combined Transcavernous Anterior and Middle Infratemporal Fossa Approach with Extracranial-Intracranial Bypass

2021 ◽  
Author(s):  
Yoichi Nonaka ◽  
Naokazu Hayashi ◽  
Takanori Fukushima
Keyword(s):  
Carotid Artery ◽  
Skull Base ◽  
Cavernous Sinus ◽  
Bypass Surgery ◽  
Internal Carotid ◽  
Infratemporal Fossa ◽  
Cavernous Sinus Meningioma ◽  
Skull Base Meningioma ◽  
Cerebral Bypass ◽  
Vessel Reconstruction

Abstract Objectives The study aims to describe surgical management of an invasive cavernous sinus meningioma with a combination of several skull base approaches and bypass surgery. Design This study is an operative video. Results Resection of the recurrent skull base meningioma is still challenging, especially if the tumor involves or encases the carotid artery. Cerebral bypass surgery is an essential adjunct in the armamentarium of skull base surgery when vessel reconstruction is required. In this paper, we describe our experience of successful treatment of an invasive recurrent skull base meningioma, which involved the entire cavernous sinus and the internal carotid artery. A 46-year-old woman presented with a 2-year history of gradually worsening left-sided exophthalmos and visual impairment. The patient had previously undergone two craniotomies for resection of the left-sided spheno-orbital meningioma. Pathological diagnosis was chordoid meningioma, which is classified as an intermediate-grade meningioma. The second surgery had been performed for a rapid tumor regrowth 6 months after the first surgery. The patient lost her left-side vision after the second surgery. Aggressive tumor regrowth was confirmed with extension into the left orbit, infratemporal fossa, and cavernous sinus with engulfment of the carotid artery. A balloon occlusion test revealed intolerance of the left internal carotid artery occlusion. Considering the patient's age, tumor behavior, and intolerance of the carotid artery of the lesion side, we scheduled gross total resection of the tumor with vessel reconstruction. Conclusion Although cerebral bypass surgery is a technically challenging procedure, it plays an important role in the surgical management of the complex vessel-engulfing tumor.The link to the video can be found at https://youtu.be/GCmpxK3hW18.

Zygomatic Approach to Cavernous Sinus Chordoma: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Antonio Aversa ◽  
Ossama Al-Mefty
Keyword(s):  
Carotid Artery ◽  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Cranial Nerves ◽  
Radical Resection ◽  
High Rate ◽  
Petrous Apex ◽  
High Dose ◽  
Middle Fossa ◽  
Cavernous Carotid Artery

Abstract Chordoma is not a benign disease. It grows invasively, has a high rate of local recurrence, metastasizes, and seeds in the surgical field.1 Thus, chordoma should be treated aggressively with radical resection that includes the soft tissue mass and the involved surrounding bone that contains islands of chordoma.2–5 High-dose radiation, commonly by proton beam therapy, is administered after gross total resection for long-term control. About half of chordoma cases occupy the cavernous sinus space and resecting this extension is crucial to obtain radical resection. Fortunately, the cavernous sinus proper extension is the easier part to remove and pre-existing cranial nerves deficit has good chance of recovery. As chordomas originate and are always present extradurally (prior to invading the dura), an extradural access to chordomas is the natural way for radical resection without brain manipulation. The zygomatic approach is key to the middle fossa, cavernous sinus, petrous apex, and infratemporal fossa; it minimizes the depth of field and is highly advantageous in chordoma located mainly lateral to the cavernous carotid artery.6–12 This article demonstrates the advantages of this approach, including the mobilization of the zygomatic arch alleviating temporal lobe retraction, the peeling of the middle fossa dura for exposure of the cavernous sinus, the safe dissection of the trigeminal and oculomotor nerves, and total control of the petrous and cavernous carotid artery. Tumor extensions to the sphenoid sinus, sella, petrous apex, and clivus can be removed. The patient is a 30-yr-old who consented for surgery.

scholarly journals Bleeding Mass in the Ear: A Rare Etiology

2015 ◽  
Vol 7 (3) ◽  
pp. 144-146
Author(s):  
John Mathew ◽  
Vinu Moses ◽  
Ann Mary Augustine ◽  
Bassin Thomas John ◽  
Anjali Lepcha
Keyword(s):  
Carotid Artery ◽  
Skull Base ◽  
External Auditory Canal ◽  
External Carotid Artery ◽  
External Carotid ◽  
Skull Base Osteomyelitis

ABSTRACT We report a case of a 63 years old man who presented with a profusely bleeding mass in the left external auditory canal. He had been diagnosed to have left skull base osteomyelitis and had undergone surgery twice for the same. The mass was diagnosed radiologically to be a pseudoaneurysm arising from the left retroauricular artery. He subsequently underwent embolization of the retroauricular branch of the left external carotid artery following which the mass subsided and bleeding from the ear stopped. How to cite this article John BT, Augustine AM, Lepcha A, Mathew J, Moses V. Bleeding Mass in the Ear: A Rare Etiology. Int J Otorhinolaryngol Clin 2015;7(3):144-146.

Orbital Vascular And Lymphatic Systems

2012 ◽  
Author(s):  
David Jordan ◽  
Louise Mawn ◽  
Richard L. Anderson
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cavernous Sinus ◽  
Ophthalmic Artery ◽  
Internal Carotid ◽  
External Carotid Artery ◽  
External Carotid ◽  
Sympathetic Nerve Fibers ◽  
Carotid Canal ◽  
Cervical Ganglion

The anatomy of the orbital vascular bed is complex, with tremendous individual variation. The main arterial supply to the orbit is from the ophthalmic artery, a branch of the internal carotid artery. The external carotid artery normally contributes only to a small extent. However, there are a number of orbital branches of the ophthalmic artery that anastomose with adjacent branches from the external carotid artery, creating important anastomotic communications between the internal and external carotid arterial systems. The venous drainage of the orbit occurs mainly via two ophthalmic veins (superior and inferior) that extend to the cavernous sinus, but there are also connections with the pterygoid plexus of veins, as well as some more anteriorly through the angular vein and the infraorbital vein to the facial vein. A working knowledge of the orbital vasculature and lymphatic systems is important during orbital, extraocular, or ocular surgery. Knowing the anatomy of the blood supply helps one avoid injury to the arteries and veins during operative procedures within the orbit or the eyelid. Inadvertent injury to the vasculature not only distorts the anatomy and disrupts a landmark but also prolongs the surgery and might compromise blood flow to an important orbital or ocular structure. Upon entering the cranium, the internal carotid artery passes through the petrous portion of the temporal bone in the carotid canal and enters the cavernous sinus and middle cranial fossa through the superior part of the forame lacerum . It proceeds forward in the cavernous sinus with the abducens nerve along its side. There it is surrounded by sympathetic nerve fibers (the carotid plexus ) derived from the superior cervical ganglion. It then makes an upward S-shaped turn to form the carotid siphon , passing just medial to the oculomotor, trochlear, and ophthalmic nerves (V1). After turning superiorly in the anterior cavernous sinus, the carotid artery perforates the dura at the medial aspect of the anterior clinoid process and turns posteriorly, inferior to the optic nerve.

scholarly journals Saphenous vein graft bypass in the treatment of giant cavernous sinus aneurysms: report of two cases

2000 ◽  
Vol 58 (1) ◽  
pp. 162-168 ◽  
Author(s):  
RICARDO RAMINA ◽  
MURILO S. MENESES ◽  
ARI A PEDROZO ◽  
WALTER O. ARRUDA ◽  
GUILHERME BORGES
Keyword(s):  
Carotid Artery ◽  
Cavernous Sinus ◽  
Saphenous Vein ◽  
Vein Graft ◽  
Saphenous Vein Graft ◽  
Brain Infarction ◽  
Superficial Temporal Artery ◽  
High Flow ◽  
Low Flow ◽  
External Carotid

Two cases of giant intracavernous aneurysms treated by high flow bypass with saphenous vein graft between the external carotid artery (ECA) and branches of the middle cerebral artery (MCA) are presented. Very often these aneurysms are unclippable because they are fusiform or have a large neck. Occlusion of the internal carotid artery (ICA) is the treatment of choice in many cases. This procedure has however a high risk of brain infarction. Revascularization of the brain by extra-intracranial anastomosis between the superficial temporal artery (STA) and branches of the MCA is frequently performed. This procedure provides however a low flow bypass and brain infarction may occur. We report two cases of giant cavernous sinus aneurysms treated by high flow bypass and endovascular balloon occlusion of the ICA. Immediate high flow revascularization of MCA branches was achieved and the patients showed no ischemic events. Follow-up of 8 and 14 months after operation shows patency of the venous graft and no neurological deficits. Angiographic control examination showed complete aneurysm occlusion in both cases.

Cavernous Sinus Meningioma: Tumor Decompression for Trigeminal Neuralgia and Anterior Tibial Artery Graft High-Flow Bypass for Brain Ischemia: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Zeeshan Qazi ◽  
Sneha Chitra Balasubramanian ◽  
Josh Abecassis ◽  
Juan P Carrasco Hernandez ◽  
Varadaraya S Shenoy ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Trigeminal Neuralgia ◽  
Cavernous Sinus ◽  
External Carotid Artery ◽  
High Flow ◽  
External Carotid ◽  
Anterior Tibial Artery ◽  
Tibial Artery ◽  
Artery Graft ◽  
Anterior Tibial

Abstract A 62-yr-old man with left cavernous sinus tumor presented with atypical trigeminal neuralgia refractory to medical treatment. He received Gamma Knife (Elekta) radiation for the tumor. However, the facial pain worsened after radiation. Neuropsychological testing done for memory problems had revealed mild neurocognitive disorder. Neurological examination showed trigeminal distribution numbness and partial abducens nerve paralysis. Imaging revealed an enhancing left cavernous sinus and supra-cavernous mass. Angiography revealed severe stenosis of the left cavernous internal carotid artery (ICA). Computed tomography (CT) perfusion study showed diminished blood flow on the left side, and ischemic changes were seen in fluid-attenuated inversion-recovery (FLAIR) magnetic resonance imaging (MRI).  Surgical resection of the tumor was preferred over ablative treatment for trigeminal neuralgia because of its effectiveness in improving cranial nerve (CN) function.1 The patient underwent staged surgeries. In the first stage, the tumor was partially excised with decompression of the trigeminal ganglion and nerve root in the lateral cavernous sinus wall, Meckel's cave. Postoperatively, MR angiography revealed worsening of the left ICA caliber. Therefore, a high-flow bypass from the external carotid artery to the middle cerebral artery (MCA) was performed with an anterior tibial artery graft. The patient recovered initially but developed enterococcus meningitis postoperatively, which was promptly identified and treated with antibiotics. At 1-yr follow-up, the graft was patent, and the patient had significant relief of his facial pain and cognitively improved.  This 2-dimensional video demonstrates the technique of partial excision of cavernous sinus meningioma with CN decompression, and the technique of a high-flow bypass from the external carotid artery to M2 MCA segment using an anterior tibial artery graft.  The patient gave informed consent for surgery and video recording. All relevant patient identifiers have been removed from the video and accompanying radiology slides.

Pitfalls during the Embolization and Evaluation after the Embolization for the Skull Base Meningiomas

1995 ◽  
Vol 8 (6) ◽  
pp. 252-257
Author(s):  
A. Nishio ◽  
K. Ohata ◽  
N. Tsuyuguchi ◽  
T. Gotoh ◽  
T. Ishiguro ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Skull Base ◽  
Internal Carotid ◽  
Serum Levels ◽  
External Carotid Artery ◽  
External Carotid ◽  
Preoperative Embolization ◽  
Mri Findings ◽  
Skull Base Meningiomas

Pitfall during the embolization and evaluation after the embolization for skull base meningiomas supplied by meningeal arteries of internal carotid artery (ICA) are reported. This study includes 15 cases of skull base meningiomas (two males and 13 females) that supplied by meningeal branches of internal carotid artery. The preoperative embolization was performed by these feeders. MRI findings and serum levels of C-reactive protein (CRP) after the embolization were examined. In ten patients among 15 patients the meningeal branches of ICA were dominant feeders. In ten patients out of 15 patients, the embolization from the meningeal branches of ICA was possible. Eight patients out of these ten patients were suffered from high fever and increase of serum level of CRP after the embolization. During the embolization for skull base meningiomas, the existence of collateral pathways between the ICA system and external carotid artery system were identified. The increase of serum levels of CRP might be recognized in the patients that effective embolization were performed.

scholarly journals Incidental Findings on Cone Beam Computed Tomography Studies outside of the Maxillofacial Skeleton

2016 ◽  
Vol 2016 ◽  
pp. 1-9 ◽  
Author(s):  
Sevin Barghan ◽  
Mehrnaz Tahmasbi Arashlow ◽  
Madhu K. Nair
Keyword(s):  
Lymph Node ◽  
Soft Tissue ◽  
Carotid Artery ◽  
Skull Base ◽  
Incidental Findings ◽  
Cervical Vertebrae ◽  
Large Field ◽  
External Carotid ◽  
Pharyngeal Airway ◽  
Base Of Skull

Objective. To define the presence and prevalence of incidental findings in and around the base of skull from large field-of-view CBCT of the maxillofacial region and to determine their clinical importance.Methods. Four hundred consecutive large fields of view CBCT scans viewed from January 1, 2007, to January 1, 2014, were retrospectively evaluated for incidental findings of the cervical vertebrae and surrounding structures. Findings were categorized into cervical vertebrae, intracranial, soft tissue, airway, carotid artery, lymph node, and skull base findings.Results. A total of 653 incidental findings were identified in 309 of the 400 CBCT scans. The most prevalent incidental findings were soft tissue calcifications (29.71%), followed by intracranial calcifications (27.11%), cervical vertebrae (20.06%), airway (11.49%), external carotid artery calcification (10.41%), lymph node calcification (0.77%), subcutaneous tissue calcification and calcified tendonitis of the longus colli muscle (0.3%), and skull base finding (0.15%). A significant portion of the incidental findings (31.24%) required referral, 17.76% required monitoring, and 51% did not require either.Conclusion. A comprehensive review of the CBCT images beyond the region of interest, especially incidental findings in the base of skull, cervical vertebrae, pharyngeal airway, and soft tissue, is necessary to avoid overlooking clinically significant lesions.

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