scholarly journals Retrosigmoid intradural suprameatal approach to Meckel's cave and the middle fossa: surgical technique and outcome

1999 ◽  
Vol 7 (6) ◽  
pp. E1
Author(s):  
Madjid Samii ◽  
Marcos Tatagiba ◽  
Gustavo A. Carvalho
Keyword(s):  
Tumor Resection ◽  
Petrous Bone ◽  
Neurological Deficits ◽  
Subtotal Resection ◽  
Middle Fossa ◽  
Meckel’S Cave ◽  
Simpson Grade ◽  
Petroclival Meningiomas ◽  
Meckel's Cave

Object The goal of this study was to determine whether some petroclival tumors can be safely and efficiently treated using a modified retrosigmoid petrosal approach that is called the retrosigmoid intradural suprameatal approach (RISA). Methods The RISA was introduced in 1983, and since that time 12 patients harboring petroclival meningiomas have been treated using this technique. The RISA includes a retrosigmoid craniotomy and drilling of the suprameatus petrous bone, which is located above and anterior to the internal auditory meatus, thus providing access to Meckel's cave and the middle fossa. Radical tumor resection (Simpson Grade I or II) was achieved in nine (75%) of the 12 patients. Two patients underwent subtotal resection (Simpson Grade III), and one patient underwent complete resection of tumor at the posterior fossa with subtotal resection at the middle fossa. There were no deaths or severe complications in this series; all patients did well postoperatively, being independent at the time of their last follow-up examinations (mean 5.6 years). Neurological deficits included facial paresis in one patient and worsening of hearing in two patients. Conclusions The approach described here is a useful modification of the retrosigmoid approach, which allows resection of large petroclival tumors without the need for supratentorial craniotomies. Although technically meticulous, this approach is not time consuming; it is safe and can produce good results. This is the first report on the use of this approach for petroclival meningiomas.

Retrosigmoid intradural suprameatal approach to Meckel's cave and the middle fossa: surgical technique and outcome

2000 ◽  
Vol 92 (2) ◽  
pp. 235-241 ◽  
Author(s):  
Madjid Samii ◽  
Marcos Tatagiba ◽  
Gustavo A. Carvalho
Keyword(s):  
Tumor Resection ◽  
Neurological Deficits ◽  
Subtotal Resection ◽  
Middle Fossa ◽  
Meckel’S Cave ◽  
Content Type ◽  
Simpson Grade ◽  
Petroclival Meningiomas ◽  
Meckel's Cave ◽  
Fine Print

Object. The goal of this study was to determine whether some petroclival tumors can be safely and efficiently treated using a modified retrosigmoid petrosal approach that is called the retrosigmoid intradural suprameatal approach (RISA).Methods. The RISA was introduced in 1983, and since that time 12 patients harboring petroclival meningiomas have been treated using this technique. The RISA includes a retrosigmoid craniotomy and drilling of the suprameatus petrous bone, which is located above and anterior to the internal auditory meatus, thus providing access to Meckel's cave and the middle fossa.Radical tumor resection (Simpson Grade I or II) was achieved in nine (75%) of the 12 patients. Two patients underwent subtotal resection (Simpson Grade III), and one patient underwent complete resection of tumor at the posterior fossa with subtotal resection at the middle fossa. There were no deaths or severe complications in this series; all patients did well postoperatively, being independent at the time of their last follow-up examinations (mean 5.6 years). Neurological deficits included facial paresis in one patient and worsening of hearing in two patients.Conclusions. Theapproach described here is a useful modification of the retrosigmoid approach, which allows resection of large petroclival tumors without the need for supratentorial craniotomies. Although technically meticulous, this approach is not time-consuming; it is safe and can produce good results. This is the first report on the use of this approach for petroclival meningiomas.

scholarly journals Trochlear Nerve Repair during Retrosigmoid Suprameatal Approach for Petrotentorial Meningioma: Operative Video

2018 ◽  
Vol 79 (S 05) ◽  
pp. S404-S406
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno ◽  
Nobuyuki Nakajima ◽  
Norio Ichimasu
Keyword(s):  
Nerve Repair ◽  
Tumor Resection ◽  
Neurological Deficits ◽  
Sensory Impairment ◽  
Trochlear Nerve ◽  
Meckel’S Cave ◽  
Meckel's Cave ◽  
Skull Base Lesions ◽  
Superior Petrosal Vein

When operating on difficult skull base lesions, it is essential to be able to handle unexpected intraoperative findings or troubles, while achieving maximal lesion removal and minimal functional deficit. This video demonstrates a case of trochlear nerve repair that was performed during the retrosigmoid suprameatal approach for treatment of a petrotentorial meningioma, extending into the Meckel's cave. The patient is a 47-year-old woman with a right petrotentorial meningioma, extending into the Meckel's cave. The retrosigmoid suprameatal approach was performed with preservation of the superior petrosal vein. However, a divided trochlear nerve was incidentally found during tumor resection. We hence carefully dissected both nerve ends from the tumor without shortening their lengths, and repaired them by end-to-end anastomosis, using fibrin glue without any graft materials. The tumor was removed completely and the patient's preoperative facial sensory impairment disappeared after the surgery. The patient's facial sensory impairment disappeared completely, but she had transient diplopia after the surgery. However, the newly developed diplopia resolved completely, and she had no neurological deficits or tumor recurrence during the follow-up period of 1-year.The link to the video can be found at: https://youtu.be/g-B-w_zDudg.

scholarly journals Pretemporal trans–Meckel’s cave transtentorial approach for large petroclival meningiomas

2018 ◽  
Vol 44 (4) ◽  
pp. E10 ◽  
Author(s):  
Chih-Hsiang Liao ◽  
Jui-To Wang ◽  
Chun-Fu Lin ◽  
Shao-Ching Chen ◽  
Chung-Jung Lin ◽  
...  
Keyword(s):  
Neurological Deficits ◽  
Partial Recovery ◽  
Total Removal ◽  
Meckel’S Cave ◽  
Petroclival Meningiomas ◽  
Meckel's Cave ◽  
Length Width ◽  
The Mean ◽  
Subtotal Removal ◽  
Transtentorial Approach

OBJECTIVEDespite the advances in skull base techniques, large petroclival meningiomas (PCMs) still pose a challenge to neurosurgeons. The authors’ objective of this study was to describe a pretemporal trans–Meckel’s cave transtentorial approach for large PCMs and to report the surgical outcomes.METHODSFrom 2014 to 2017, patients harboring large PCMs (> 3 cm) and undergoing their first resection via this procedure at the authors’ institute were included. In combination with pretemporal transcavernous and anterior transpetrosal approaches, the trans–Meckel’s cave transtentorial route was created. Surgical details are described and a video demonstrating the procedure is included. Retrospective review of the medical records and imaging studies was performed.RESULTSA total of 18 patients (6 men and 12 women) were included in this study, with mean age of 53 years. The mean sizes of the preoperative and postoperative PCMs were 4.36 cm × 4.09 cm × 4.13 cm (length × width × height) and 0.83 cm × 1.08 cm × 0.75 cm, respectively. Gross-total removal was performed in 7 patients, near-total removal (> 95%) in 7 patients, and subtotal removal in 4 patients (> 90% in 3 patients and > 85% in 1 patient). There were no surgical deaths or patients with postoperative hemiplegia. Surgical complications included transient cranial nerve (CN) III palsy (all patients, resolved in 3 months), transient CN VI palsy (2 patients), CN IV palsy (3 patients, partial recovery), hydrocephalus (3 patients), and CSF otorrhea (1 patient). Temporal lobe retraction–related neurological deficits were not observed.CONCLUSIONSA pretemporal trans–Meckel’s cave transtentorial approach offers large surgical exposure and multiple trajectories to the suprasellar, interpeduncular, prepontine, and upper-half clival regions without overt traction, which is mandatory to remove large PCMs. To unlock Meckel’s cave where a large PCM lies abutting the cave, pretemporal transcavernous and anterior transpetrosal approaches are prerequisites to create adequate exposure for the final trans–Meckel’s cave step.

scholarly journals Extended middle fossa approach with anterior petrosectomy for resection of upper petroclival meningioma involving Meckel’s cave: operative video and technical nuances

2017 ◽  
Vol 43 (videosuppl2) ◽  
pp. V8 ◽  
Author(s):  
James K. Liu
Keyword(s):  
Surgical Management ◽  
Cranial Nerve ◽  
Cranial Nerves ◽  
Middle Fossa ◽  
Meckel’S Cave ◽  
Petroclival Meningioma ◽  
Middle Fossa Approach ◽  
Petroclival Meningiomas ◽  
Meckel's Cave ◽  
Anterior Petrosectomy

The surgical management of petroclival meningiomas remains a formidable challenge. These tumors are deep in the base of the skull and arise medial to the fifth cranial nerve. In this operative video, the author demonstrates the extended middle fossa approach with anterior petrosectomy to resect an upper petroclival meningioma extending into Meckel’s cave with brainstem compression. This approach is very useful for accessing deep tumors located above and below the tentorium, and between the fifth and seventh cranial nerves. Access to Meckel’s cave is readily achieved by opening the fibrous ring of the porous trigeminus. This video demonstrates the operative technique and surgical nuances of the skull base approach, useful anatomic landmarks of the middle fossa rhomboid for safe petrosectomy drilling, pearls for cranial nerve and neuro-otologic preservation, and exposure of Meckel’s cave. A gross-total resection was achieved, and the patient was neurologically intact. In summary, the extended middle fossa approach with anterior petrosectomy is an important strategy in the armamentarium for surgical management of petroclival meningiomas.The video can be found here: https://youtu.be/jttwJIYPHC8.

scholarly journals Intracranial plasmacytoma arising from dura mater secondary to multiple myeloma and presenting with sudden lethal intracerebral hemorrhage: A case report and literature review

2021 ◽  
Vol 12 ◽  
pp. 55
Author(s):  
Koki Onodera ◽  
Kota Kurisu ◽  
Seiji Takebayashi ◽  
Juro Sakurai ◽  
Tohru Kobayashi ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Intracerebral Hemorrhage ◽  
Dura Mater ◽  
Tumor Resection ◽  
Massive Hemorrhage ◽  
Bone Involvement ◽  
Neurological Deficits ◽  
Middle Fossa ◽  
Rare Manifestation

Background: Intracranial and central nervous system’s involvement with multiple myeloma (MM) is a clinically rare manifestation. Furthermore, the development of intracranial plasmacytoma without bone involvement is much rarer. Herein, we report the case of massive intracerebral hemorrhage form intracranial plasmacytoma that arose from the dura mater without bone involvement. Case Description: A 71-year-old woman, who had been diagnosed as MM and treated 2 years prior, developed sudden lethal intracerebral hemorrhage from the intracranial plasmacytoma. Massive hemorrhage was observed after a rapid tumor growth in the middle fossa. Immediate hematoma evacuation and tumor resection allowed the patient to avoid severe neurological deficits and lethal conditions. Conclusion: A close follow-up by neuroimaging studies is essential in cases of intracranial plasmacytoma in MM patients and early intervention with surgical resection or radiotherapy should be considered.

scholarly journals Petroclival Meningiomas: Factors Determining the Choice of Approach

2017 ◽  
Vol 79 (04) ◽  
pp. 367-378 ◽  
Author(s):  
Gustavo Isolan ◽  
Sâmia Wayhs ◽  
Guilherme Lepski ◽  
Leandro Dini ◽  
Joel Lavinsky
Keyword(s):  
Tumor Progression ◽  
Cranial Nerve ◽  
Tumor Resection ◽  
Retrosigmoid Approach ◽  
University Hospital ◽  
Gross Total Resection ◽  
Middle Fossa ◽  
Total Resection ◽  
Petroclival Meningiomas

Objectives To review a surgical series of petroclival meningiomas and the factors considered in the choice of approach. Design Retrospective review. Setting The study was conducted in a university hospital in southern Brazil. Participants Twenty-two patients with petroclival meningioma originating from the upper two-thirds of the clivus medial to the fifth cranial nerve. Main Outcome Measures Gross-total resection, mortality, major morbidity, new cranial nerve deficits and tumor progression or recurrence. Results Retrosigmoid approach was used in tumors <3 cm and in those at or below the internal auditory meatus. Posterior petrosectomy was performed for tumors extending into the middle fossa. Gross-total resection was performed in 11 patients (50%). The mean follow-up time was 32 months (6–75 months). There were four cases of tumor progression or recurrence, which were treated with radiosurgery. Conclusions Resection of petroclival meningiomas remains challenging. In most cases, the retrosigmoid approach was sufficient, without affecting the degree of tumor resection. Petrosal approaches were reserved for patients with tumor extension into the middle fossa.

Combined Transpetrosal Approach With Preservation of Superior Petrosal Vein Drainage for a Cerebellopontine Angle Epidermoid Cyst Extending Into Meckel's Cave: 3-Dimensional Operative Video

2018 ◽  
Vol 16 (6) ◽  
pp. E172-E173
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno ◽  
Nobuyuki Nakajima ◽  
Norio Ichimasu
Keyword(s):  
Epidermoid Cyst ◽  
Cerebellopontine Angle ◽  
Young Patients ◽  
Neurological Deficits ◽  
Meckel’S Cave ◽  
3 Dimensional ◽  
Petrosal Vein ◽  
Meckel's Cave ◽  
Superior Petrosal Sinus ◽  
Superior Petrosal Vein

Abstract The combined transpetrosal approach enables wide exposure around the petroclival region by cutting the tentorium and superior petrosal sinus. We often choose this approach for removal of tumors ventral to the facial and vestibulocochlear nerves, such as petroclival meningioma and epidermoid cyst, because complete removal of the tumor under direct visualization is required to prevent its later recurrence, especially in young patients. Recent reports revealed anatomical variations of the drainage of the superior petrosal sinus, and dural incision considering preservation of the superior petrosal vein was proposed.1-3 This 3-dimensional video shows a patient with an epidermoid cyst, which was surgically treated using the combined transpetrosal approach, with consideration of the variation of the superior petrosal sinus and preservation of the drainage route of the superior petrosal vein. The video was reproduced after informed consent of the patient. The patient is a 31-yr-old woman who presented with a left cerebellopontine angle epidermoid cyst extending into Meckel's cave. The superior petrosal sinus was of the lateral type, draining only laterally into the transverse–sigmoid junction without medial connection with the cavernous sinus.1 The combined transpetrosal approach was performed with cutting of the superior petrosal sinus medial to the entry point of the superior petrosal vein, in order to preserve its drainage into the transverse–sigmoid junction. Meckel’ cave was opened along its lateral margin, and tumor removal was accomplished, leaving only a minute part of the capsule strongly adhering to the neurovascular structures. The patient had no new permanent neurological deficits during follow-up. The figures in the video were modified from Matsushima et al1 by permission of the Congress of Neurological Surgeons.

A Side Door to Meckel's Cave: Anatomic Feasibility Study for the Lateral Transorbital Approach

2017 ◽  
Vol 13 (5) ◽  
pp. 614-621 ◽  
Author(s):  
Blake Harrison Priddy ◽  
Cristian Ferrareze Nunes ◽  
Andre Beer-Furlan ◽  
Ricardo Carrau ◽  
Iacopo Dallan ◽  
...  
Keyword(s):  
Skull Base ◽  
Surgical Navigation ◽  
Cranial Nerves ◽  
Anatomical Study ◽  
Middle Cranial Fossa ◽  
Middle Fossa ◽  
Meckel’S Cave ◽  
Side Door ◽  
Meckel's Cave ◽  
Brain Retraction

Abstract BACKGROUND: In the last decade, endoscopic skull base surgery has significantly developed and generated a plethora of techniques and approaches for access to the cranial ventral floor. However, the exploration for the least-aggressive, maximally efficient approach continues. OBJECTIVE: To describe in detail an anatomical study, along with the technical nuances of a novel endoscopic approach to Meckel's Cave (MC) using a lateral transorbital (LTO) route. METHODS: Eighteen orbits of injected cadaveric specimens were operated on, using an endoscopic LTO approach to MC, middle cranial fossa, and paramedian skull base preserving the orbital rim. Surgical navigation and an after-the-fact infratemporal craniectomy were utilized to identify the limits of the approach. RESULTS: Following a transorbital approach opening a trapezoid window at the superolateral aspect (average 166.7 mm2), a middle fossa “peeling” and full visualization of MC was accomplished with no difficulties in all specimens. The entire approach was performed extradurally without the need to expose the temporal lobe. CONCLUSION: In a cadaveric model, the endoscopic LTO approach affords a direct route to access MC. Its main advantage is that it is minimally disruptive in nature, less brain retraction is required, and it reaches the middle fossa in an anterolateral perspective. It also requires no manipulation of the temporalis muscle, limited cosmetic incision, and rapid recovery. It seems a viable alternative to traditional approaches for lesions lateral to the cranial nerves at the cavernous sinus and MC, that is, schwannomas. Clinical utilization of this approach will challenge its efficacy and identify limitations.

scholarly journals Posterior Approach to Meckel's Cave: Retrosigmoid Craniectomy with Endoscopic Assistance

2019 ◽  
Vol 80 (S 03) ◽  
pp. S331-S332
Author(s):  
Paramita Das ◽  
Hamid Borghei-Razavi ◽  
Nina Z. Moore ◽  
Pablo F. Recinos
Keyword(s):  
Tumor Resection ◽  
Cranial Nerves ◽  
Auditory Brainstem ◽  
Technical Note ◽  
Auditory Brainstem Responses ◽  
Case Review ◽  
Meckel’S Cave ◽  
Meckel's Cave ◽  
Endoscopic Assistance ◽  
Loss Of Hearing

Background Meckel's cave involvement in tumors pose a challenge due to their surrounding neurovascular structure and deep location. Case Review A 24-year-old male presented with progressive headaches and right sided trigeminal neuralgia with a large epidermoid. The tumor extended from the ambient cistern to the cerebellomedullary cistern and involved Meckel's cave (Fig. 1). Technical Note/Video Description A retrosigmoid craniectomy was performed. Cranial nerves 3, 4, 6, 7, and 10, and auditory brainstem responses were monitored. Once the craniectomy was completed the dura was opened and cerebrospinal fluid (CSF) was released from the cisterna magna to allow for the tumor resection to be done without the use of any retractors (Fig. 2). Care was taken to ensure that cranial nerves in the posterior fossa were detethered to prevent any traction injury. Using ring curettes the pearly white epidermoid tumor was able to be debulked. After all the possible tumor was resected with the microscope, the 30-degree endoscope was used to identify the porus trigeminus. Malleable ring curettes and a malleable suction were used to remove the soft tumor from this location. The patient transiently had loss of hearing but this returned within 2 weeks after surgery. Conclusions The retrosigmoid approach is familiar to all neurosurgeons and with the adjunct of an angled endoscope, the posterior Meckel's cave can be easily reached. This is particularly useful for tumors with soft consistency. The assistance of the endoscope allows Meckel's cave visualization without additional drilling while still allowing safe resection of tumor from around the trigeminal nerve.The link to the video can be found at: https://youtu.be/01aqOyUmSW0.

Diagnostic and therapeutic values of intraoperative electrophysiological neuromonitoring during resection of intradural extramedullary spinal tumors: a single-center retrospective cohort and meta-analysis

2019 ◽  
Vol 30 (6) ◽  
pp. 839-849 ◽  
Author(s):  
Wataru Ishida ◽  
Joshua Casaos ◽  
Arun Chandra ◽  
Adam D’Sa ◽  
Seba Ramhmdani ◽  
...  
Keyword(s):  
Evoked Potentials ◽  
Predictive Value ◽  
Meta Analysis ◽  
Tumor Resection ◽  
Diagnostic Value ◽  
Neurological Deficits ◽  
Spinal Tumors ◽  
Intradural Extramedullary ◽  
Baseline Characteristics

OBJECTIVEWith the advent of intraoperative electrophysiological neuromonitoring (IONM), surgical outcomes of various neurosurgical pathologies, such as brain tumors and spinal deformities, have improved. However, its diagnostic and therapeutic value in resecting intradural extramedullary (ID-EM) spinal tumors has not been well documented in the literature. The objective of this study was to summarize the clinical results of IONM in patients with ID-EM spinal tumors.METHODSA retrospective patient database review identified 103 patients with ID-EM spinal tumors who underwent tumor resection with IONM (motor evoked potentials, somatosensory evoked potentials, and free-running electromyography) from January 2010 to December 2015. Patients were classified as those without any new neurological deficits at the 6-month follow-up (group A; n = 86) and those with new deficits (group B; n = 17). Baseline characteristics, clinical outcomes, and IONM findings were collected and statistically analyzed. In addition, a meta-analysis in compliance with the PRISMA guidelines was performed to estimate the overall pooled diagnostic accuracy of IONM in ID-EM spinal tumor resection.RESULTSNo intergroup differences were discovered between the groups regarding baseline characteristics and operative data. In multivariate analysis, significant IONM changes (p < 0.001) and tumor location (thoracic vs others, p = 0.018) were associated with new neurological deficits at the 6-month follow-up. In predicting these changes, IONM yielded a sensitivity of 82.4% (14/17), specificity of 90.7% (78/86), positive predictive value (PPV) of 63.6% (14/22), negative predictive value (NPV) of 96.3% (78/81), and area under the curve (AUC) of 0.893. The diagnostic value slightly decreased in patients with schwannomas (AUC = 0.875) and thoracic tumors (AUC = 0.842). Among 81 patients who did not demonstrate significant IONM changes at the end of surgery, 19 patients (23.5%) exhibited temporary intraoperative exacerbation of IONM signals, which were recovered by interruption of surgical maneuvers; none of these patients developed new neurological deficits postoperatively. Including the present study, 5 articles encompassing 323 patients were eligible for this meta-analysis, and the overall pooled diagnostic value of IONM was a sensitivity of 77.9%, a specificity of 91.1%, PPV of 56.7%, and NPV of 95.7%.CONCLUSIONSIONM for the resection of ID-EM spinal tumors is a reasonable modality to predict new postoperative neurological deficits at the 6-month follow-up. Future prospective studies are warranted to further elucidate its diagnostic and therapeutic utility.

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