Contralateral transmaxillary corridor: an augmented endoscopic approach to the petrous apex

OBJECTIVEThe endoscopic endonasal approach (EEA) has been shown to be an effective means of accessing lesions of the petrous apex. Lesions that are lateral to the paraclival segment of the internal carotid artery (ICA) require lateralization of the paraclival segment of the ICA or a transpterygoid infrapetrous approach. In this study the authors studied the feasibility of adding a contralateral transmaxillary (CTM) corridor to provide greater access to the petrous apex with decreased need for manipulation of the ICA.METHODSUsing image guidance, EEA and CTM extension were performed bilaterally on 5 cadavers. The anterior wall of the sphenoid sinus and rostrum were removed. The angle of the surgical approach from the axis of the petrous segment of the ICA was measured. Five illustrative clinical cases are presented.RESULTSThe CTM corridor required a partial medial maxillectomy. When measured from the axis of the petrous ICA, the CTM corridor decreased the angle from 44.8° ± 2.78° to 20.1° ± 4.31°, a decrease of 24.7° ± 2.58°. Drilling through the CTM corridor allowed the drill to reach lateral aspects of the petrous apex that would have required lateralization of the ICA or would not have been accessible via EEA. The CTM corridor allowed us to achieve gross-total resection of the petrous apex region in 5 clinical cases with significant paraclival extension.CONCLUSIONSThe CTM corridor is a feasible extension to the standard EEA to the petrous apex that offers a more lateral trajectory with improved access. This approach may reduce the risk and morbidity associated with manipulation of the paraclival ICA.

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Transcavernous Resection of a Giant Extensive Chondrosarcoma with Endoscopic Assistance

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1727124 ◽

2021 ◽

Author(s):

Walid Elshamy ◽

Burcak Soylemez ◽

Sima Sayyahmelli ◽

Nese Keser ◽

Mustafa K. Baskaya

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Skull Base ◽

Internal Carotid ◽

Gross Total Resection ◽

Petrous Apex ◽

Left Internal Carotid Artery ◽

Total Resection ◽

Complete Occlusion ◽

Grade Ii

AbstractChondrosarcomas are one of the major malignant neoplasms which occur at the skull base. These tumors are locally invasive. Gross total resection of chondrosarcomas is associated with longer progression-free survival rates. The patient is a 55-year-old man with a history of dysphagia, left eye dryness, hearing loss, and left-sided facial pain. Magnetic resonance imaging (MRI) showed a giant heterogeneously enhancing left-sided skull base mass within the cavernous sinus and the petrous apex with extension into the sphenoid bone, clivus, and the cerebellopontine angle, with associated displacement of the brainstem (Fig. 1). An endoscopic endonasal biopsy revealed a grade-II chondrosarcoma. The patient was then referred for surgical resection. Computed tomography (CT) scan and CT angiogram of the head and neck showed a left-sided skull base mass, partial destruction of the petrous apex, and complete or near-complete occlusion of the left internal carotid artery. Digital subtraction angiography confirmed complete occlusion of the left internal carotid artery with cortical, vertebrobasilar, and leptomeningeal collateral development. The decision was made to proceed with a left-sided transcavernous approach with possible petrous apex drilling. During surgery, minimal petrous apex drilling was necessary due to autopetrosectomy by the tumor. Endoscopy was used to assist achieving gross total resection (Fig. 2). Surgery and postoperative course were uneventful. MRI confirmed gross total resection of the tumor. The histopathology was a grade-II chondrosarcoma. The patient received proton therapy and continues to do well without recurrence at 4-year follow-up. This video demonstrates steps of the combined microsurgical skull base approaches for resection of these challenging tumors.The link to the video can be found at: https://youtu.be/WlmCP_-i57s.

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Petrous Apex Granulomas: CT and MR Imaging

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100120955 ◽

2002 ◽

Vol 29 (2) ◽

pp. 169-170 ◽

Cited By ~ 1

Author(s):

Stephen Hentschel ◽

Felix Durity

Keyword(s):

Sphenoid Sinus ◽

Internal Carotid ◽

Lateral Wall ◽

Petrous Apex ◽

High Signal ◽

Horizontal Canal ◽

Computed Tomography Scanning ◽

History Of ◽

Tomography Scanning ◽

Sixth Nerve

A 29-year-old male complained of a four month history of horizontal, spontaneous, and nonprogressive diplopia. On examination he had a mild left sixth nerve palsy. The rest of his general and neurologic examinations were normal.Computed tomography scanning demonstrated a nonenhancing, well-circumscribed, lesion in the left petrous apex (Figure 1). The opposite apex was well pneumatized. The lesion abutted the medial wall of the horizontal canal of the internal carotid artery and pointed towards the lateral wall of the sphenoid sinus. Unfortunately, CT bone windows were not available for this case but would have been helpful in terms of the differential diagnosis. An MRI demonstrated a predominantly high signal mass on T1 and T2 sequences (Figure 2). The diagnosis was a petrous apex granuloma.

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Pneumatization Patterns of the Petrous Apex and Lateral Sphenoid Recess

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0037-1603972 ◽

2017 ◽

Vol 78 (06) ◽

pp. 441-446 ◽

Cited By ~ 2

Author(s):

Margherita Bruni ◽

Robert Wong ◽

Mark Tabor ◽

K. Boyev ◽

Alexander Malone

Keyword(s):

Sphenoid Sinus ◽

Normative Data ◽

Image Guidance ◽

Pearson Correlation ◽

Petrous Apex ◽

Lateral Recess ◽

Poor Access ◽

Level I ◽

Temporal Bones ◽

Future Work

Introduction The petrous apex poses a challenge for surgical intervention due to poor access. As intraoperative image guidance and surgical instrumentation improve, newer endoscopic approaches are increasingly favored. This study aims to provide normative data on the anatomy of the lateral sphenoid sinus recess and petrous apex. These normative data could assist in determining the efficacy of a transnasal transsphenoidal approach to lesions of the anteroinferior petrous apex. Methods This is a retrospective study investigating normative data on all maxillofacial computed tomography (CT) scans performed at a level I trauma center over a 6-month period. All appropriate images had the pneumatization pattern of the petrous apex and lateral recess of the sphenoid sinus reviewed by a single otologist and graded bilaterally. These were then analyzed in SPSS; Pearson correlation analyses and χ2 test were used. Results A total of 481 patients were identified, yielding a total of 962 temporal bones and sphenoid sinuses for analysis. Eighty-eight percent of sides analyzed had a nonpneumatized lateral recess. The petrous apex was nonpneumatized in 54% of sides analyzed. There was a correlation noted between the degree of pneumatization of the petrous apex and pneumatization of the lateral recess of the sphenoid. Conclusion This study is the first to provide normative data comparing pneumatization of the petrous apex and sphenoid sinus. These data may support future work evaluating the utility of an endonasal approach to the petrous apex.

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Endoscopic endonasal surgical management of chondrosarcomas with cerebellopontine angle extension

Neurosurgical FOCUS ◽

10.3171/2014.7.focus14349 ◽

2014 ◽

Vol 37 (4) ◽

pp. E13 ◽

Cited By ~ 21

Author(s):

Paulo M. Mesquita Filho ◽

Leo F. S. Ditzel Filho ◽

Daniel M. Prevedello ◽

Cristian A. N. Martinez ◽

Mariano E. Fiore ◽

...

Keyword(s):

Skull Base ◽

Posterior Fossa ◽

Cerebellopontine Angle ◽

Tumor Resection ◽

Petrous Bone ◽

Petrous Apex ◽

Total Resection ◽

Endoscopic Endonasal ◽

Female Ratio ◽

Male Female Ratio

Object Skull base chondrosarcomas are slow-growing, locally invasive tumors that arise from the petroclival synchondrosis. These characteristics allow them to erode the clivus and petrous bone and slowly compress the contents of the posterior fossa progressively until the patient becomes symptomatic, typically from cranial neuropathies. Given the site of their genesis, surrounded by the petrous apex and the clival recess, these tumors can project to the middle fossa, cervical area, and posteriorly, toward the cerebellopontine angle (CPA). Expanded endoscopic endonasal approaches are versatile techniques that grant access to the petroclival synchondrosis, the core of these lesions. The ability to access multiple compartments, remove infiltrated bone, and achieve tumor resection without the need for neural retraction makes these techniques particularly appealing in the management of these complex lesions. Methods Analysis of the authors’ database yielded 19 cases of skull base chondrosarcomas; among these were 5 cases with predominant CPA involvement. The electronic medical records of the 5 patients were retrospectively reviewed for age, sex, presentation, pre- and postoperative imaging, surgical technique, pathology, and follow-up. These cases were used to illustrate the surgical nuances involved in the endonasal resection of CPA chondrosarcomas. Results The male/female ratio was 1:4, and the patients’ mean age was 55.2 ±11.2 years. All cases involved petrous bone and apex, with variable extensions to the posterior fossa and parapharyngeal space. The main clinical scenario was cranial nerve (CN) palsy, evidenced by diplopia (20%), ptosis (20%), CN VI palsy (20%), dysphagia (40%), impaired phonation (40%), hearing loss (20%), tinnitus (20%), and vertigo/dizziness (40%). Gross-total resection of the CPA component of the tumor was achieved in 4 cases (80%); near-total resection of the CPA component was performed in 1 case (20%). Two patients (40%) harbored high-grade chondrosarcomas. No patient experienced worsening neurological symptoms postoperatively. In 2 cases (40%), the symptoms were completely normalized after surgery. Conclusions Expanded endoscopic endonasal approaches appear to be safe and effective in the resection of select skull base chondrosarcomas; those with predominant CPA involvement seem particularly amenable to resection through this technique. Further studies with larger cohorts are necessary to test these preliminary impressions and to compare their effectiveness with the results obtained with open approaches.

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Paratrigeminal, Paraclival, Precavernous, or All of the Above? A Circumferential Anatomical Study of the C3-C4 Transitional Segment of the Internal Carotid Artery

Operative Neurosurgery ◽

10.1093/ons/opx121 ◽

2017 ◽

Vol 14 (4) ◽

pp. 432-440 ◽

Cited By ~ 2

Author(s):

Eleonora Marcati ◽

Norberto Andaluz ◽

Sebastien C Froelich ◽

Lee A Zimmer ◽

James L Leach ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Cavernous Sinus ◽

Internal Carotid ◽

Anatomical Study ◽

Posterior Longitudinal Ligament ◽

Petrous Apex ◽

Meckel’S Cave ◽

Endoscopic Endonasal ◽

Meckel's Cave

Abstract BACKGROUND Although the term paraclival carotid pervades recent skull base literature, no clear consensus exists regarding boundaries or anatomical segments. OBJECTIVE To reconcile various internal carotid artery (ICA) nomenclatures for transcranial and endoscopic-endonasal perspectives, we reexamined the transition between lacerum (C3) and cavernous (C4) segments using a C1-C7 segments schema. In this cadaveric study, we obtained a 360°-circumferential view integrating histological, microsurgical, endoscopic, and neuroradiological analyses of this C3-C4 region and identified a distinct transitional segment. METHODS In 13 adult, silicone-injected, formalin-fixed cadaveric heads (26 sides), transcranial-extradural-subtemporal and endoscopic-endonasal CTguided dissections were performed. A quadrilateral area was noted medial to Meckel's cave between cranial nerve VI, anterolateral and posterolateral borders of the lateral-paratrigeminal aspect of the precavernous ICA, and posterior longitudinal ligament. Endoscopically, a medial-paraclival aspect was defined. Anatomical correlations were made with histological and neuroradiological slides. RESULTS We identified a distinct precavernous C3-C4 transitional segment. In 18 (69%) specimens, venous channels were absent at the quadrilateral area, on the paratrigeminal border of the precavernous ICA. A trigeminal membrane, seen consistently on the superior border of V2, defined the lateral aspect of the cavernous sinus floor. The medial aspect of the precavernous ICA corresponded with the paraclival ICA. CONCLUSION Our study revealing the juncture of 2 complementary borders of the ICA, endoscopic endonasal (paraclival) and transcranial (paratrigeminal), reconciles various nomenclature. A precavernous segment may clarify controversies about the paraclival ICA and support the concept of a “safe door” for lesions involving Meckel's cave, cavernous sinus, and petrous apex.

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Ultrasound Doppler examination in the surgical treatment of pituitary adenomas with cavernous sinus extension

Ukrainian Neurosurgical Journal ◽

10.25305/unj.222868 ◽

2021 ◽

Vol 27 (1) ◽

pp. 29-33

Author(s):

Ruslan V. Aksyonov ◽

Orest I. Palamar ◽

Andrii P. Huk ◽

Dmytro I. Okonskyi ◽

Dmytro S. Teslenko

Keyword(s):

Surgical Treatment ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Doppler Ultrasound ◽

Cavernous Sinus ◽

Pituitary Adenomas ◽

Internal Carotid ◽

Gross Total Resection ◽

Total Resection ◽

Endoscopic Endonasal

Objective: To determine the effectiveness of intraoperative Doppler ultrasound in the surgical treatment of pituitary adenomas with invasive parasellar growth into the cavernous sinus Knosp 3 and Knosp 4. Material and Methods. During 2009–2017, 71 patients with pituitary adenomas (PA) with extension into the cavernous sinus Knosp 3 and Knosp 4 were retrospectively reviewed. According to the size PA were divided into pituitary macroadenomas, (from 10 to 40 mm) in 45 (63.4%) patients, and giant PA (over 40 mm) – in 26 (36.6%) patients. Cavernous sinus invasion Knosp 3 and 4 was identified in 47 (66.2%) and 24 (33.8%) patients respectively. Non-secreting PA - 43 (60.5%) patients and hormone-secreting PA - 28 patients (39.4%). Endoscopic endonasal trassphenoidal (EET) approach was used in all cases. Laterally expanded EET (LEEET) approach was used in 29 cases. Intraoperative Doppler ultrasound (IDUS) was used in 36 (51%) cases. Results. Intraoperative Doppler ultrasound was used in cases of Knosp 3 extension in 23 (32.4%) cases and in Knosp 4 - in 13 (18.3%) cases. Gross total resection, including extension into the cavernous sinus using IDUS was achieved in 22 (62.7%) patients. In cases where IDUS was not used, gross total resection was achieved in 19 (52.7%) cases. In cases where the IDUS was not used, recurrence rate was 7.3%, with IDUS - 5%. Biochemical remission was achieved in 22 (78.6%) cases. Liquorrhea nasalis after surgery was observed in 6 (8.4%) cases, meningoencephalitis - in 1 (1.4%) case, oculomotor palsy -3 (4.2%) cases. Conclusions. Intraoperative Doppler ultrasound is an informative method that provides safe resection of pituitary adenomas with cavernous sinus extension with a low level of possible postoperative complications. Parasellar extension of Pituitary adenomas into the cavernous sinus Knosp 4 significantly reduces the possibility of gross total resection. However, the use of intraoperative ultrasound makes it possible to determine safe boundaries for manipulation both medially and laterally from the internal carotid artery, increasing the level of radicality and the duration of clinical remission. Intraoperative Doppler ultrasound during endoscopic endonasal transsphenoidal surgery of pituitary adenomas with parasellar extension allows to identify the internal carotid artery in the tumor stroma with the existing changed skull base anatomy. Dura incision under intraoperative Doppler ultrasound reduces the risk of internal carotid artery injury.

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Endoscopic Localization of the Anterior and Posterior Ethmoid Arteries

Annals of Otology Rhinology & Laryngology ◽

10.1177/000348940811701212 ◽

2008 ◽

Vol 117 (12) ◽

pp. 931-935 ◽

Cited By ~ 30

Author(s):

Joseph K. Han ◽

Samuel S. Becker ◽

Steven R. Bomeli ◽

Charles W. Gross

Keyword(s):

Skull Base ◽

Sphenoid Sinus ◽

Image Guidance ◽

Middle Turbinate ◽

Anterior Wall ◽

Guidance System ◽

External Incision ◽

The Mean ◽

Endoscopic Localization ◽

Anterior Ethmoid Artery

Objectives: Understanding the endoscopic locations of the anterior and posterior ethmoid arteries is important during endoscopic sinus or endoscopic skull base procedures so that these arteries can be avoided. Therefore, the objective of this study was to define the endoscopic locations of the ethmoid arteries. Methods: Twenty-four cadaver heads were used to identify the endoscopic location of the ethmoid arteries via an external incision. An image guidance system was used to record the locations of these arteries. The anterior ethmoid artery was referenced to the axilla of the middle turbinate, and the posterior ethmoid artery to the anterior wall of the sphenoid sinus. The closest lamella to these arteries was identified. Results: Forty-eight nasal cavities were dissected. The mean distance from the axilla to the anterior ethmoid artery was 17.5 mm. The anterior ethmoid artery was located immediately anterior to (31%), at (36%), or immediately posterior to (33%) the superior attachment of the basal lamella. The mean distance from the posterior ethmoid artery to the anterior ethmoid artery was 14.9 mm. The mean distance from the posterior ethmoid artery to the anterior wall of the sphenoid sinus was 8.1 mm. The posterior ethmoid artery was either anterior to (98%) or at (2%) the anterior face of the sphenoid sinus. Conclusions: Specific endoscopic anatomic relationships and measurements have been presented for the anterior and posterior ethmoid arteries.

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The endoscopic, endonasal, transmaxillary transpterygoid approach to the pterygopalatine fossa, infratemporal fossa, petrous apex, and the Meckel cave

Journal of Neurosurgery ◽

10.3171/2009.10.jns09157 ◽

2010 ◽

Vol 113 (5) ◽

pp. 967-974 ◽

Cited By ~ 87

Author(s):

Christoph P. Hofstetter ◽

Ameet Singh ◽

Vijay K. Anand ◽

Ashutosh Kacker ◽

Theodore H. Schwartz

Keyword(s):

Skull Base ◽

Sphenoid Sinus ◽

Infratemporal Fossa ◽

Pterygopalatine Fossa ◽

Csf Leak ◽

Petrous Apex ◽

Subtotal Resection ◽

Endoscopic Endonasal ◽

Lateral Skull Base ◽

Neural Origin

Object In this paper the authors' goal was to present their clinical experience with lesions of the pterygopalatine fossa, infratemporal fossa, lateral sphenoid sinus, cavernous sinus, petrous apex, and Meckel cave using simple and extended endoscopic transpterygoid approaches to the lateral skull base. Methods Simple and expanded endoscopic transpterygoid approaches were performed in a series of 13 patients with varying pathology that included lateral sphenoid sinus encephaloceles, benign and malignant sinonasal tumors, and lesions of neural origin. Results A gross-total resection was achieved in 5 of 9 patients, while a subtotal resection for tissue diagnosis and cytoreduction prior to further adjuvant treatment was performed in the remaining patients. Sphenoid sinus encephaloceles were successfully repaired via a transpterygoid approach in all 4 patients. The skull base defect was reconstructed using a multilayered closure. One patient developed a postoperative CSF leak, which was successfully treated conservatively. The mean follow-up time was 16 months. Five patients complained of recurrent sinusitis. One patient experienced xerophthalmia and palate numbness. Three patients had died by the time of this report. Two patients died of unrelated causes. The third patient died of progression of an aggressive pterygopalatine osteosarcoma despite undergoing cytoreductive surgery and adjuvant chemotherapy. Conclusions An endoscopic transpterygoid approach is a minimally invasive endoscopic approach for lesions located or extending to the pterygopalatine fossa, infratemporal fossa, petrous apex, Meckel cave, and other regions of the paramedian skull base.

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A Road Map to the Internal Carotid Artery in Expanded Endoscopic Endonasal Approaches to the Ventral Cranial Base

Operative Neurosurgery ◽

10.1227/neu.0000000000000362 ◽

2014 ◽

Vol 10 (3) ◽

pp. 448-471 ◽

Cited By ~ 34

Author(s):

Mohamed A. Labib ◽

Daniel M. Prevedello ◽

Ricardo Carrau ◽

Edward E. Kerr ◽

Cristian Naudy ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Carotid Bifurcation ◽

Cranial Base ◽

Reference Points ◽

Petrous Apex ◽

Endoscopic Endonasal ◽

Carotid Canal ◽

Road Map

Abstract BACKGROUND: Injuring the internal carotid artery (ICA) is a feared complication of endoscopic endonasal approaches. OBJECTIVE: To introduce a comprehensive ICA classification scheme pertinent to safe endoscopic endonasal cranial base surgery. METHODS: Anatomic dissections were performed in 33 cadaveric specimens (bilateral). Anatomic correlations were analyzed. RESULTS: Based on anatomic correlations, the ICA may be described as 6 distinct segments: (1) parapharyngeal (common carotid bifurcation to ICA foramen); (2) petrous (carotid canal to posterolateral aspect of foramen lacerum); (3) paraclival (posterolateral foramen lacerum to the superomedial aspect of the petrous apex); (4) parasellar (superomedial petrous apex to the proximal dural ring); (5) paraclinoid (from the proximal to the distal dural rings); and (6) intradural (distal ring to ICA bifurcation). Corresponding surgical landmarks included the Eustachian tube, the fossa of Rosenmüller, and levator veli palatini for the parapharyngeal segment; the vidian canal and V3 for the petrous segment; the fibrocartilage of foramen lacerum, foramen rotundum, maxillary strut, lingular process of the sphenoid bone, and paraclival protuberance for the paraclival segment; the sellar floor and petrous apex for the parasellar segment; and the medial and lateral opticocarotid and lateral tubercular recesses, as well as the distal osseous arch of the carotid sulcus for the paraclinoid segment. CONCLUSION: The proposed endoscopic classification outlines key anatomic reference points independent of the vessel's geometry or the sinonasal pneumatization, thus serving as (1) a practical guide to navigate the ventral cranial base while avoiding injury to the ICA and (2) further foundation for a modular access system.

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The pterygoclival ligament: a novel landmark for localization of the internal carotid artery during the endoscopic endonasal approach

Journal of Neurosurgery ◽

10.3171/2017.12.jns172435 ◽

2019 ◽

Vol 130 (5) ◽

pp. 1699-1709 ◽

Cited By ~ 1

Author(s):

Ali Tayebi Meybodi ◽

Andrew S. Little ◽

Vera Vigo ◽

Arnau Benet ◽

Sofia Kakaizada ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Fibrous Tissue ◽

Petrous Apex ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Pterygoid Process ◽

The Mean

OBJECTIVEThe transpterygoid extension of the endoscopic endonasal approach provides exposure of the petrous apex, Meckel’s cave, paraclival area, and the infratemporal fossa. Safe and efficient localization of the lacerum segment of the internal carotid artery (ICA) is a crucial part of such exposure. The aim of this study is to introduce a novel landmark for localization of the lacerum ICA.METHODSTen cadaveric heads were prepared for transnasal endoscopic dissection. The floor of the sphenoid sinus was drilled to expose an extension of the pharyngobasilar fascia between the sphenoid floor and the pterygoid process (the pterygoclival ligament). Several features of the pterygoclival ligament were assessed. In addition, 31 dry skulls were studied to assess features of the bony groove harboring the pterygoclival ligament.RESULTSThe pterygoclival ligament was identified bilaterally during drilling of the sphenoid floor in all specimens. The ligament started a few millimeters posterior to the posterior end of the vomer alae and invariably extended posterolaterally and superiorly to blend into the fibrous tissue around the lacerum ICA. The mean length of the ligament was 10.5 ± 1.7 mm. The mean distance between the anterior end of the ligament and midline was 5.2 ± 1.2 mm. The mean distance between the posterior end of the ligament and midline was 12.3 ± 1.4 mm. The bony pterygoclival groove was identified at the confluence of the vomer, pterygoid process of the sphenoid, and basilar part of the occipital bone, running from posterolateral to anteromedial. The mean length of the groove was 7.7 ± 1.8 mm. Its posterolateral end faced the anteromedial aspect of the foramen lacerum medial to the posterior end of the vidian canal. A clinical case illustration is also provided.CONCLUSIONSThe pterygoclival ligament is a consistent landmark for localization of the lacerum ICA. It may be used as an adjunct or alternative to the vidian nerve to localize the ICA during endoscopic endonasal surgery.

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