scholarly journals Cavum trigeminale cephalocele associated with intracranial hypertension in an 18-month-old child: illustrative case

2021 ◽  
Vol 1 (22) ◽  
Author(s):  
Giovanni Miccoli ◽  
Domenico Cicala ◽  
Pietro Spennato ◽  
Alessia Imperato ◽  
Claudio Ruggiero ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Cerebrospinal Fluid Leak ◽  
Petrous Apex ◽  
Illustrative Case ◽  
Meckel’S Cave ◽  
Facial Numbness ◽  
Meckel's Cave ◽  
Fluid Leak ◽  
Visual Disturbances ◽  
Sustained Increase

BACKGROUND Cavum trigeminale cephaloceles (CTCs) are characterized by a cystic appearance and extension of the posterolateral aspect of Meckel’s cave into the superomedial portion of the petrous apex. A possible mechanism is a transient or sustained increase of intracranial pressure transmitted to Meckel’s cave, leading to its secondary herniation, in the presence of predisposing local factors. The majority of CTCs are incidental findings. Among symptomatic cases, headache, trigeminal neuralgia, cerebrospinal fluid leak, vertigo, ataxia, facial numbness, hearing loss, diplopia, and other visual disturbances have been described. OBSERVATIONS The authors describe a case of an 18-month-old male patient referred to their hospital with drowsiness, vomiting, left cranial nerve VI palsy, and papilledema. Neuroradiological investigation revealed the presence of a CTC with a swollen aspect of the left pontine hemisection and indirect signs of intracranial hypertension. The patient was managed with implantation of a ventriculoperitoneal shunt. LESSONS CTCs are rare lesions that are difficult to recognize on neuroimaging, in which they can be mistaken for tumoral or inflammatory lesions. The most frequent asymptomatic forms should be considered as “leave-me-alone” lesions. In cases of intracranial hypertension, according to a supposed theory on the origin of CTCs, the authors recommend treating only the intracranial hypertension instead of performing more invasive surgical procedures, especially in pediatric patients.

Microsurgical Anatomy of the Endoscopy-Assisted Retrosigmoid Intradural Suprameatal Approach to the Meckel's Cave

2021 ◽  
Author(s):  
Yuanzhi Xu ◽  
Benjamin K Hendricks ◽  
Maximiliano Alberto Nunez ◽  
Ahmed Mohyeldin ◽  
Juan C Fernandez-Miranda ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Internal Auditory Canal ◽  
Semicircular Canals ◽  
Petrous Apex ◽  
Microsurgical Anatomy ◽  
Meckel’S Cave ◽  
Meckel's Cave ◽  
Trigeminal Root

Abstract BACKGROUND Understanding the microsurgical anatomical features of the endoscopy-assisted retrosigmoid intradural suprameatal approach (RISA) is critical for surgeons treating petroclival tumors or lesions in the cerebellopontine region that extend into Meckel's cave. OBJECTIVE To evaluate increased exposure for Meckel's cave in the RISA and assess the surgical landmarks for this approach. METHODS A standard retrosigmoid craniotomy to the cerebellopontine region was performed in 4 cadaveric specimens (8 hemispheres) with microscope-assisted endoscopy. The length and depth of the drilling region from the suprameatal tubercle to the petrous apex were analyzed. After opening Meckel's cave and mobilizing the trigeminal root completely, the landmarks for this approach were investigated. RESULTS The endoscopy-assisted RISA facilitates mobilization of the trigeminal root and enhances surgical exposure in the region of Meckel's cave and the petrous apex with increases of 10.1 ± 1.3 mm in depth, 21.4 ± 3.2 mm in length, and 6.4 ± 0.6 mm in height. The posterior and superior semicircular canals, internal auditory canal, superior petrous sinus, and internal carotid artery (petrous segment) served as important landmarks for this approach. One case illustration is presented to describe the application of this approach. CONCLUSION The RISA is suitable mainly for lesions in the posterior fossa that extend into Meckel's cave. The endoscopy-assisted reach optimizes accessibility to the petrous apex region, obviates the need for extensive drilling, and decreases the risk of internal carotid artery injury. Better realization and recognition of microsurgical landmarks and parameters of this approach are crucial for successful outcomes.

Microsurgical Resection of a Petroclival Epidermoid Cyst Using an Anterior Petrosectomy Approach: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Kunal V Vakharia ◽  
Ryan M Naylor ◽  
Ashley M Nassiri ◽  
Colin L W Driscoll ◽  
Michael J Link
Keyword(s):  
Epidermoid Cyst ◽  
Cranial Nerves ◽  
Residual Tumor ◽  
Middle Meningeal Artery ◽  
Neural Tube Closure ◽  
Petrous Apex ◽  
Meckel’S Cave ◽  
Postoperative Mri ◽  
Meckel's Cave ◽  
Anterior Petrosectomy

Abstract Epidermoid cysts are rare, benign lesions that result from inclusion of ectodermal elements during neural tube closure.1 Cysts are composed of desquamated epithelial cells and restrict diffusion on magnetic resonance imaging (MRI).2,3 Symptoms are attributable to anatomic location.4,5 In this video, we illustrate the surgical treatment of an epidermoid cyst located in the right cerebellopontine angle, petrous apex, and Meckel's cave. The patient, a 33-yr-old female with right-sided V1 trigeminal hypoesthesia, underwent surveillance imaging for 2 yr. However, she developed progressive V1 and V2 trigeminal hypoesthesia and imaging revealed enlargement of the lesion. Therefore, surgical resection was pursued. The patient consented to the procedure. The patient underwent a right middle fossa craniotomy and anterior petrosectomy. After identifying the greater superficial petrosal nerve and cutting the middle meningeal artery as it exited foramen spinosum, Kawase's triangle was drilled, and the dura over Meckel's cave and the subtemporal dura were opened. The lesion was resected, taking care to preserve the trigeminal nerve and the basilar artery. A retrosigmoid craniotomy was then fashioned. The cyst and its capsule were dissected off the brainstem and cranial nerves utilizing natural corridors between the trigeminal and vestibulocochlear nerves as well as between the facial and lower cranial nerves. Gross total resection was confirmed on postoperative MRI, and she was discharged home on postoperative day 5. Three months after surgery, she underwent formal pinprick testing, which revealed 95% loss of sensation in V1, 20% loss in V2, and normal sensation in V3. Three-month postoperative MRI showed no residual tumor.

Trigeminal Neuralgia Caused by Venous Compression

Neurosurgery ◽  
2004 ◽  
Vol 55 (2) ◽  
pp. 334-339 ◽  
Author(s):  
Toshio Matsushima ◽  
Phuong Huynh-Le ◽  
Masayuki Miyazono
Keyword(s):  
Trigeminal Neuralgia ◽  
Trigeminal Nerve ◽  
Microvascular Decompression ◽  
Complete Relief ◽  
Surgical Results ◽  
Meckel’S Cave ◽  
Trigeminal Pain ◽  
Venous Compression ◽  
Facial Numbness ◽  
Meckel's Cave

Abstract OBJECTIVE: The purpose of this study is to clarify whether venous compression on the trigeminal nerve really causes trigeminal neuralgia or not, and to identify which veins are the offending veins. METHODS: We used microvascular decompression in operations on 121 patients with typical trigeminal neuralgia. We analyzed the intraoperative findings and surgical results in these 121 cases. RESULTS: In 7 of the 121 cases, only the vein was identified as a compressive factor on the trigeminal nerve. In 6 of these 7 cases, single venous compression was found, whereas the remaining case had two offending veins. The transverse pontine vein was most frequently found as the offending vein near Meckel's cave. All patients showed complete relief of trigeminal pain after decompression of the veins, but four of them developed facial numbness after surgery, which tended to be slight and did not require any treatment. CONCLUSION: Our surgical experiences showed that venous compression could cause trigeminal neuralgia by itself and that the transverse pontine vein should be carefully observed because it is most frequently the offending vein.

Combined Petrosal Approach for Resection of a Large Trigeminal Schwannoma With Meckel's Cave Involvement—Part I: Anatomic Rationale and Analysis: 2-Dimensional Operative Video

2020 ◽  
Author(s):  
Ali Tayebi Meybodi ◽  
James K Liu
Keyword(s):  
Cerebellopontine Angle ◽  
Skin Incision ◽  
Petrous Apex ◽  
Successful Management ◽  
Meckel’S Cave ◽  
Trigeminal Schwannoma ◽  
Skull Base Approach ◽  
Meckel's Cave ◽  
History Of ◽  
Anterior Petrosectomy

Abstract Resection of large trigeminal schwannomas involving both posterior and middle cranial fossae is challenging. The depth of the surgical target in the superomedial corner of the cerebellopontine angle and the petrous apex makes for a difficult lesion to favorably access, expose, and safely resect. Judicious planning of a skull base approach is therefore the most crucial step in successful management of these formidable tumors. When properly chosen, planned, and executed, the combined petrosal approach sets the stage for an optimal exposure of such tumors that involve both posterior and middle cranial fossae. The present video is the first of a 2-part video presentation that explains the anatomic rationale of selecting a combined petrosal approach (anterior petrosectomy and retrolabyrinthine petrosectomy) for the resection of a large trigeminal schwannoma involving the posterior and middle cranial fossae with an extension into Meckel's cave in a 54-yr-old female presenting with 5-yr history of increasing headaches, left-sided face numbness, and disequilibrium. The benefits, risks, and alternatives of the surgical procedure were discussed in detail with the patient and she consented to proceed with surgery. Part I also discusses the important nuances of positioning the patient, as well as planning and execution of the skin incision, including pericranial flap harvesting.  Of note, the patient consented to the publication of images obtained from her.

The Subtemporal Interdural Approach to Dumbbell-Shaped Trigeminal Schwannomas: Cadaveric Prosection

2006 ◽  
Vol 59 (suppl_4) ◽  
pp. ONS-270-ONS-278 ◽  
Author(s):  
Samy Youssef ◽  
Eun-Young Kim ◽  
Khaled M.A. Aziz ◽  
Salah Hemida ◽  
Jeffrey T. Keller ◽  
...  
Keyword(s):  
Cleavage Plane ◽  
Histological Study ◽  
Petrous Apex ◽  
Gasserian Ganglion ◽  
Middle Fossa ◽  
Meckel’S Cave ◽  
Anterior Transpetrosal Approach ◽  
Single Compartment ◽  
Meckel's Cave ◽  
Superior Petrosal Sinus

Abstract OBJECTIVE: Successful resection of dumbbell-shaped trigeminal schwannomas via a subtemporal interdural approach requires an understanding of both the anatomy related to the bone dissection of the petrous apex (Kawase's triangle or quadrilateral) and meningeal anatomy. We studied the meningeal anatomy related to this approach and describe the dural incisions and stepwise mobilization. METHODS: Meningeal anatomy around Meckel's cave and porus trigeminus was examined during the subtemporal interdural anterior transpetrosal approach in both sides of 15 cadaveric heads. Histological study of the Meckel's cave region was performed in two cadaveric heads. RESULTS: The Gasserian ganglion and trigeminal roots have two layers of dura propria on their dorsolateral surface: an inner layer from the posterior fossa dura propria that constitutes the dorsolateral wall of Meckel's cave and an outer layer from the dura propria of the middle fossa. The cleavage plane between these two layers continues distally as the cleavage plane between the epineural sheaths of the trigeminal divisions and the dura propria of the middle fossa. This cleavage plane serves as the anatomic landmark for the interdural exposure of the contents of Meckel's cave. The superior petrosal sinus is sectioned at the medial aspect of Kawase's triangle and reflected along with the porus trigeminus roof. CONCLUSION: Understanding the critical meningeal architecture in and around Meckel's cave allows experienced cranial neurosurgeons to develop a subtemporal interdural approach to dumbbell-shaped trigeminal schwannomas that effectively converts a multiple-compartment tumor into a single-compartment tumor. Dural incisions and stepwise mobilization complements our previous description of the bony dissection for this approach.

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

2017 ◽  
Vol 14 (4) ◽  
pp. 432-440 ◽  
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.

Gorham-Stout Syndrome of the Petrous Apex Causing Chronic Cerebrospinal Fluid Leak

2010 ◽  
Vol 31 (5) ◽  
pp. 789-792 ◽  
Author(s):  
Sharon L. Cushing ◽  
Gisele Ishak ◽  
Jonathan A. Perkins ◽  
Jay T. Rubinstein
Keyword(s):  
Cerebrospinal Fluid ◽  
Cerebrospinal Fluid Leak ◽  
Petrous Apex ◽  
Fluid Leak

scholarly journals A Case of Petrous Apex Meningocele: Unusual Presentation of Cerebrospinal Fluid Leak Following Adenoidectomy

2020 ◽  
Vol 27 (2) ◽  
pp. 135-139
Author(s):  
Byung Kil Kim ◽  
Yujin Heo ◽  
Doo-Sik Kong ◽  
Sang Duk Hong
Keyword(s):  
Cerebrospinal Fluid ◽  
Bacterial Meningitis ◽  
Cerebrospinal Fluid Leak ◽  
Csf Leak ◽  
Petrous Apex ◽  
Diagnostic Process ◽  
Recurrent Meningitis ◽  
Csf Rhinorrhea ◽  
Leakage Site ◽  
Fluid Leak

Cerebrospinal fluid (CSF) leak is possible and can be a cause of recurrent bacterial meningitis. Petrous apex meningocele (PAM) is mostly asymptomatic and is often found during incidental imaging tests. We experienced a case of CSF rhinorrhea with recurrent meningitis in bilateral PAM after adenoidectomy. This report highlights the diagnostic process of CSF leak, identification of leakage site, and surgical approach to petrous apex lesions.

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