Minimally Invasive Subtemporal Intradural Approach for Penetrating Orbitocranial Injury by Wooden Foreign Body Into the Lateral Wall of the Cavernous Sinus

Introduction. A transorbital intracranial injury with a foreign body can be a very complex and controversial therapeutic problem. The orbit's content is susceptible to penetrating trauma, and neurovascular skull base structures are at high risk from injury. There are some traditional cranial surgical approaches, and more recently reported different endoscopic approaches for treating this kind of injury. Case report. We present a case of a 30-year-old male who had an accident at work when a piece of wood hit him in his head and entered through the medial aspect of his left orbit with skull base and cavernous sinus injury. Rapid and complete radiological and clinical assessments were performed, and the patient was treated in a minimally invasive manner. The foreign body was manually extracted with an endoscopic and endovascular team ready to treat adverse events. No postoperative complications were reported, and visual acuity increased at one month follow up. Conclusion. Penetrating wounds of the orbit represent a challenge that requires a multidisciplinary assessment and well-organized management. Combined endoscopic minimally invasive approaches should be considered during the treatment of this kind of injury.

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Combined and simultaneous endoscopic endonasal and transorbital surgery for a Meckel’s cave schwannoma: technical nuances of a mini-invasive, multiportal approach

Journal of Neurosurgery ◽

10.3171/2020.4.jns20707 ◽

2020 ◽

pp. 1-10

Author(s):

Alberto Di Somma ◽

Cristobal Langdon ◽

Matteo de Notaris ◽

Luis Reyes ◽

Santiago Ortiz-Perez ◽

...

Keyword(s):

Minimally Invasive ◽

Skull Base ◽

Cavernous Sinus ◽

Lateral Wall ◽

Neurological Deficits ◽

Meckel’S Cave ◽

Endoscopic Endonasal ◽

Endoscopic Transorbital ◽

Meckel's Cave ◽

Surgical Teams

OBJECTIVEOver the years, Meckel’s cave pathologies have been judged off-limits because of high rates of morbidity. Even though several studies have defined various surgical routes with tolerable morbidity and mortality rates, controversies related to the optimal avenue to treat different categories of Meckel’s cave and cavernous sinus neoplasms persist.With unceasing energy to cultivate minimally invasive neurosurgical approaches, the endoscopic endonasal route has been tested, and the approach effectively performed, to provide a valid surgical window to these areas. In this dynamic and challenging scenario, another ventral endoscopic minimally invasive route—that is, the superior eyelid endoscopic transorbital approach—has been very recently proposed, and used in selected cases, to access the cavernous sinus and Meckel’s cave regions.METHODSThe authors report the technical nuances of a combined and simultaneous endoscopic endonasal and transorbital surgical treatment of a patient with a Meckel’s cave schwannoma. The operation involved collaboration among neurosurgery, otorhinolaryngology, and ophthalmology (oculoplastic surgery). The patient recovered well, had no neurological deficits, and was discharged to home 3 days after surgery.RESULTSThe multiportal combined route was proposed for the following reasons. The endonasal approach, considered to be more familiar to our skull base team, could allow control of possible damage of the internal carotid artery. From the endonasal perspective, the most inferior and medial portion of the tumor could be properly managed. Finally, the transorbital route, by means of opening the lateral wall of the cavernous sinus via the meningoorbital band, could allow control of the superolateral part of the tumor and, most importantly, could permit removal of the portion entering the posterior cranial fossa via the trigeminal pore. Simultaneous surgery with two surgical teams working together was planned in order to reduce operative time, hospital stay, and patient stress and discomfort, and to ensure “one-shot” complete tumor removal, with minimal or no complications.CONCLUSIONSThis study represents the translation into the real surgical setting of recent anatomical contributions related to the novel endoscopic transorbital approach and its simultaneous integration with the endoscopic endonasal pathway. Accordingly, it may pave the way for future applications related to minimally invasive, multiportal endoscopic surgery for skull base tumors.

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The Anteromedial Triangle: The Risk for Cranial Nerve Ischemia at the Cavernous Sinus Lateral Wall. Anatomic Cadaveric Study

Skull Base ◽

10.1055/s-2009-1222402 ◽

2009 ◽

Vol 19 (01) ◽

Author(s):

Michele Conti ◽

Daniel Prevedello ◽

Andreas Schwarz ◽

Roger Robert ◽

Amin Kassam

Keyword(s):

Cavernous Sinus ◽

Cranial Nerve ◽

Lateral Wall ◽

Cadaveric Study

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ORBITOCRANIAL WOODEN FOREIGN BODY RETRIEVED BY A TRANSCRANIAL SUPERIOR ORBITOTOMY APPROACH

10.26226/morressier.578e3b52d462b80292382d2c ◽

2016 ◽

Author(s):

Mark Wilson

Keyword(s):

Foreign Body ◽

Wooden Foreign Body

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Intraorbital Wooden Foreign Body with Intracranial Extension : A Case Report

Ophthalmologica Indonesiana ◽

10.35749/journal.v44i1.155 ◽

2018 ◽

Vol 44 (1) ◽

pp. 4

Author(s):

Amanda N Shinta ◽

Purjanto Tepo Utomo ◽

Agus Supartoto

Keyword(s):

Visual Acuity ◽

Foreign Body ◽

Frontal Lobe ◽

Vital Sign ◽

Intracranial Extension ◽

Ocular Motility ◽

Light Perception ◽

Bone Segment ◽

Wooden Foreign Body ◽

Wooden Stick

Purpose : The aim of this study is to report a case of intraorbital wooden foreign body with intracranial extension to the frontal lobe and its management. Method : This is a descriptive study: A 53 year-old male referred due to wooden stick stucked in the orbital cavity causing protruding eyeball and vital sign instability. Result : Right eye examination revealed light perception visual acuity, with bad light projection and bad color perception, inwardly folded upper eyelid, proptosis, conjunctival chemosis, corneal erosion and edema, dilated pupil with sluggish pupillary light reflex and limited ocular movement in all direction. Vital sign was unstable with decreasing blood pressure, increasing temperature and heart rate. CT Scan showed complete fracture of the orbital roof due to penetration of the wooden stick, pneumoencephalus, cerebral edema and hematoma. Emergency craniotomy was performed to remove the penetrating wooden stick and bone segment in the frontal lobe and fracture repair. Ophthalmologist pulled the remaining stick, released the superior rectus muscle and repaired the lacerated eyelid. Outcome visual acuity was no light perception with lagophthalmos and limited ocular motility. Patient was admitted to Intensive Care Unit one day post-operatively and treated with systemic and topical antibiotic. Conclusion : Any case presenting with intraorbital foreign body must undergo immediate neuroimaging to exclude any intracranial extension, especially in patients with worsening general condition.

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Intraorbital wooden foreign body detected by computed tomography and magnetic resonance imaging

The Neuroradiology Journal ◽

10.1177/1971400916678245 ◽

2016 ◽

Vol 30 (1) ◽

pp. 88-91 ◽

Cited By ~ 3

Author(s):

Alfredo Di Gaeta ◽

Francesco Giurazza ◽

Eugenio Capobianco ◽

Alvaro Diano ◽

Mario Muto

Keyword(s):

Computed Tomography ◽

Foreign Body ◽

Magnetic Resonance ◽

Delayed Diagnosis ◽

Clinical History ◽

Definitive Diagnosis ◽

Double Vision ◽

Resonance Imaging ◽

Wooden Foreign Body ◽

The Right

To identify and localize an intraorbital wooden foreign body is often a challenging radiological issue; delayed diagnosis can lead to serious adverse complications. Preliminary radiographic interpretations are often integrated with computed tomography and magnetic resonance, which play a crucial role in reaching the correct definitive diagnosis. We report on a 40 years old male complaining of pain in the right orbit referred to our hospital for evaluation of eyeball pain and double vision with an unclear clinical history. Computed tomography and magnetic resonance scans supposed the presence of an abscess caused by a foreign intraorbital body, confirmed by surgical findings.

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Trans-zygomatic middle cranial fossa approach to access lesions around the cavernous sinus and anterior parahippocampus: a minimally invasive skull base approach

Acta Neurochirurgica ◽

10.1007/s00701-009-0376-4 ◽

2009 ◽

Vol 151 (8) ◽

pp. 977-982 ◽

Cited By ~ 5

Author(s):

Itay Melamed ◽

R. Shane Tubbs ◽

Troy D. Payner ◽

Aaron A. Cohen-Gadol

Keyword(s):

Minimally Invasive ◽

Skull Base ◽

Cavernous Sinus ◽

Middle Cranial Fossa ◽

Base Approach ◽

Middle Cranial Fossa Approach ◽

Skull Base Approach ◽

Cranial Fossa

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The Medial Wall of the Cavernous Sinus: Microsurgical Anatomy

Neurosurgery ◽

10.1227/01.neu.0000126953.59406.77 ◽

2004 ◽

Vol 55 (1) ◽

pp. 179-190 ◽

Cited By ~ 75

Author(s):

Alexandre Yasuda ◽

Alvaro Campero ◽

Carolina Martins ◽

Albert L. Rhoton ◽

Guilherme C. Ribas

Keyword(s):

Pituitary Gland ◽

Cavernous Sinus ◽

Thin Sheet ◽

Single Layer ◽

Lateral Wall ◽

The Body ◽

Medial Wall ◽

Microsurgical Anatomy ◽

Pituitary Fossa ◽

Adjacent Structures

Abstract OBJECTIVE: This study was conducted to clarify the boundaries, relationships, and components of the medial wall of the cavernous sinus (CS). METHODS: Forty CSs, examined under ×3 to ×40 magnification, were dissected from lateral to medial in a stepwise fashion to expose the medial wall. Four CSs were dissected starting from the midline to lateral. RESULTS: The medial wall of the CS has two parts: sellar and sphenoidal. The sellar part is a thin sheet that separates the pituitary fossa from the venous spaces in the CS. This part, although thin, provided a barrier without perforations or defects in all cadaveric specimens studied. The sphenoidal part is formed by the dura lining the carotid sulcus on the body of the sphenoid bone. In all of the cadaveric specimens, the medial wall seemed to be formed by a single layer of dura that could not be separated easily into two layers as could the lateral wall. The intracavernous carotid was determined to be in direct contact with the pituitary gland, being separated from it by only the thin sellar part of the medial wall in 52.5% of cases. In 39 of 40 CSs, the venous plexus and spaces in the CS extended into the narrow space between the intracavernous carotid and the dura lining the carotid sulcus, which forms the sphenoidal part of the medial wall. The lateral surface of the pituitary gland was divided axially into superior, middle and inferior thirds. The intracavernous carotid coursed lateral to some part of all the superior, middle, and inferior thirds in 27.5% of the CSs, along the inferior and middle thirds in 32.5%, along only the inferior third in 35%, and below the level of the gland and sellar floor in 5%. In 18 of the 40 CSs, the pituitary gland displaced the sellar part of the medial wall laterally and rested against the intracavernous carotid, and in 6 there was a tongue-like lateral protrusion of the gland that extended around a portion of the wall of the intracavernous carotid. No defects were observed in the sellar part of the medial wall, even in the presence of these protrusions. CONCLUSION: The CS has an identifiable medial wall that separates the CS from the sella and capsule of the pituitary gland. The medial wall has two segments, sellar and sphenoidal, and is formed by just one layer of dura that cannot be separated into two layers as can the lateral wall of the CS. In this study, the relationships between the medial wall and adjacent structures demonstrated a marked variability.

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