The extradural temporopolar approach: a review of indications and operative technique

Zada, Gabriel; Day, John D.; Giannotta, Steven L.

doi:10.3171/foc.2008.25.12.e3

Cited by 26 publications

(12 citation statements)

References 28 publications

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“…This approach offers wide visualization of the extradural structures, such as the three divisions of the trigeminal nerve and the cavernous sinus. 11,12 Arterial feeder coagulation, peeling of the MCF dura, trigeminal nerve mobilization, and petrosectomy can be achieved with minimal brain retraction during the early stage of tumor resection by this technique. In our series, there was no morbid cerebral retraction, except for the petroclival meningioma (case no.…”

Section: Discussionmentioning

confidence: 99%

Transzygomatic Approach with Intraoperative Neuromonitoring for Resection of Middle Cranial Fossa Tumors

et al. 2011

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Access to the floor of the middle cranial fossa (MCF) is often required when performing cranial base approaches to expose various lesions of the petrous apex, petroclival junction, internal auditory canal, and posterior cavernous sinus. In many patients with these lesions, a temporal craniotomy is sufficient to reach the floor of the MCF. However, the caudal limit of a simple temporal craniotomy is the zygomatic arch, which can present an obstacle in accessing the MCF in some individuals. Several authors have advocated mobilizing the zygomatic arch by performing a simple zygomatic osteotomy or using extended frontotemporo-orbitozygomatic approaches to reach low-lying lesions. [1][2][3] Intraoperative neuromonitoring (IOM) is one of the methods in which modern neurosurgery can improve surgical results while reducing morbidity. Motor-evoked potentials (MEPs) obtained by transcranial electrocortical stimulation is routinely used to monitor major motor pathways intraoperatively during several neurosurgical procedures. 4-6 Monitoring of oculomotor, trochlear, trigeminal, and facial nerve function is usually performed using free-running electromyography (EMG) or by direct stimulation of each cranial nerve. 7-9 Keywords ► middle fossa approach ► skull base surgery ► motor-evoked potentials ► intraoperative monitoring ► neurophysiology AbstractThe authors reviewed the surgical experience and operative technique in a series of 11 patients with middle fossa tumors who underwent surgery using the transzygomatic approach and intraoperative neuromonitoring (IOM) at a single institution. This approach was applied to trigeminal schwannomas (n ¼ 3), cavernous angiomas (n ¼ 3), sphenoid wing meningiomas (n ¼ 3), a petroclival meningioma (n ¼ 1), and a hemangiopericytoma (n ¼ 1). An osteotomy of the zygoma, a low-positioned frontotemporal craniotomy, removal of the remaining squamous temporal bone, and extradural drilling of the sphenoid wing made a flat trajectory to the skull base. Total resection was achieved in 9 of 11 patients. Significant motor pathway damage can be avoided using a change in motor-evoked potentials as an early warning sign. Four patients experienced cranial nerve palsies postoperatively, even though free-running electromyography of cranial nerves showed normal responses during the surgical procedure. A simple transzygomatic approach provides a wide surgical corridor for accessing the cavernous sinus, petrous apex, and subtemporal regions. Knowledge of the middle fossa structures is essential for anatomic orientation and avoiding injuries to neurovascular structures, although a neuronavigation system and IOM helps orient neurosurgeons.

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Section: Discussionmentioning

confidence: 99%

Transzygomatic Approach with Intraoperative Neuromonitoring for Resection of Middle Cranial Fossa Tumors

et al. 2011

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“…This technique approaches the cavernous sinus and middle fossa from an anterolateral trajectory and requires posterior and superior extradural retraction of the temporal lobe. The benefit of extradural retraction is that it does not require sectioning of temporal pole bridging veins entering the sphenoparietal sinus and extradural retraction can displace retraction forces via a small cushion of CSF [12,17,69]. Via this approach the entire middle fossa, CS, clinoidal region, and posterior fossa -via petrosectomy -can be accessed [14,17,29].…”

Section: Comparative Approachesmentioning

confidence: 98%

“…Some key additional features of this approach is that it requires sectioning of the distal carotid ring to mobilize the ICA, trans-sylvian dissection, disconnection of arachnoid attachments between the oculomotor nerve and the uncus, untethering of the oculomotor nerve at the trigone, and posterior clinoidectomy [14,57,58,60,69]. For high basilar apex aneurysms, an orbitozygomatic osteotomy can improve inferior-superior trajectory [14,59,60,69]. Multiple authors have utilized a transcavernous variation of this approach to improve access to the basilar artery [22,43,63,70].…”

Section: Comparative Approachesmentioning

confidence: 99%

“…For wider access to the interpeduncular fossa and posterior circulation aneurysms, posterior temporal lobe retraction has been employed. This extension has been referred to as "temporopolar", "pre-temporal", "anterior temporal", or "extended lateral transylvian" approach [14,[57][58][59][60]69]. Sano was one of the first to employ this approach for basilar apex aneurysms [59,60].…”

Section: Comparative Approachesmentioning

confidence: 99%

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Lateral transzygomatic middle fossa approach and its extensions: Surgical technique and 3D anatomy

Chotai

Kshettry

Petrak

et al. 2015

Clinical Neurology and Neurosurgery

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“…Parasellar meningiomas originating in the cavernous sinus, sphenoid wing, or petroclival region frequently demonstrate growth patterns extending laterally into the temporal and deep frontal regions, and often require more extended open skull base approaches to achieve adequate tumor debulking. 17,54,64 Although extended endoscopic transsphenoidal operations-and the added visual perspectives provided by angled endoscopes-may improve the extent of tumor resection, the requirement for adjunctive treatment should be anticipated in a large proportion of cases for tumors with lateral extension. In recent years, modifications of extended endoscopic skull base approaches, such as the transpterygoid and transmaxillary approaches, have improved the ability to reach lateral tumor components extending beyond the lateral limits of the ICA and into the infratemporal fossa and lateral retroclival region.…”

Section: Lateral Extension Beyond the Cavernous Sinusmentioning

confidence: 99%

Defining the “edge of the envelope”: patient selection in treating complex sellar-based neoplasms via transsphenoidal versus open craniotomy

Zada¹,

Du²,

Laws³

2011

JNS

Self Cite

116

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Since the reemergence of the transsphenoidal approach as a primary means of accessing and resecting sellar region tumors in the 1960s by Hardy and Guiot, several key advances have improved the ability to safely treat patients with larger and increasingly complex tumors of the anterior and middle skull base. 28,43 In particular, the operating microscope, extended transsphenoidal approaches, advanced neuroimaging, intraoperative neuronavigation, and neuroendoscopy have collectively improved the ability to safely treat many of these lesions. The evolution of extended transsphenoidal approaches and endoscopic instrumentation has facilitated surgical access to lesions of the midline skull base via natural corridors, along a wide arc from the frontal sinus to the odontoid process. 9,31,34,53 Equally important are recent developments in effectively reconstructing the skull base after tumor resection, thereby reducing the incidence of CSF leakage and associated infection, which has traditionally been one of the major pitfalls associated with transsphenoidal and related skull base approaches.As the subspecialty of endoscopic skull base surgery continues to "push the edge of the envelope" in regard to the spectrum of lesions that can be effectively and safely treated, the key limitations to the types and extent of tumor pathology that can be optimally resected via these approaches must be continuously reassessed. In some instances, these limitations are inherent to an individual tumor's biology and pose a surgical challenge regardless of the operative approach that is undertaken. Nevertheless, patient selection remains of paramount importance Results. Thirteen cases exemplifying some of the existing limitations to achieving optimal surgical outcomes via transsphenoidal-based approaches are presented. The following 8 factors are separately discussed that repeatedly limited the extent of resection, increased the risk of the operation, and contributed to perioperative complications: significant suprasellar extension, lateral extension, retrosellar extension, brain invasion with edema, firm tumor consistency, involvement or vasospasm of the arteries of the circle of Willis, and encasement of the optic apparatus or invasion of the optic foramina.Conclusions. Although the ability to approach and resect complex tumors using endonasal skull base techniques has evolved dramatically in recent years, several inherent tumor characteristics mandate extensive preoperative consideration. In selected cases these characteristics may lend support to selecting an open craniotomy as the initial operation. (DOI: 10.3171/2010.8.JNS10520) Key words • transsphenoidal approach • endoscopic surgery • skull base surgery • pituitary adenoma • meningioma • craniopharyngioma • invasionAbbreviations used in this paper: ACA = anterior cerebral artery; DI = diabetes insipidus; EBRT = external-beam radiation therapy; FSH = follicle-stimulating hormone; GTR = gross-total resection; ICA = internal carotid artery; PBRT = proton-beam radiation therapy; P...

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The extradural temporopolar approach: a review of indications and operative technique

Cited by 26 publications

References 28 publications

Transzygomatic Approach with Intraoperative Neuromonitoring for Resection of Middle Cranial Fossa Tumors

Transzygomatic Approach with Intraoperative Neuromonitoring for Resection of Middle Cranial Fossa Tumors

Lateral transzygomatic middle fossa approach and its extensions: Surgical technique and 3D anatomy

Defining the “edge of the envelope”: patient selection in treating complex sellar-based neoplasms via transsphenoidal versus open craniotomy

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