The Petrosal Approach: Indications, Technique, and Results

Al‐Mefty, Ossama; Ayoubi, Samer; Smith, Robert R.

doi:10.1007/978-3-7091-9183-5_27

Cited by 105 publications

(53 citation statements)

References 5 publications

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“…The oculomotor and trochlear nerves are the most vulnerable nerves resulting in this complication owing to the trajectory through the cavernous sinus and tentorial incisura. 17,18 Therefore, EMG and nerve conduction studies have been used to monitor the oculomotor, trochlear, trigeminal, abducens, and facial nerves during surgery in the MCF. [19][20][21] In our series, a free-running EMG of the third, fifth, and seventh cranial nerves failed to predict new neurologic deficits postoperatively, although direct electrical stimulation could help to identify and distinguish the cranial nerves.…”

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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“…In contrast to other skull base approaches, such as anterior, anterolateral, and posterolateral routes, which are routinely described for accessing extraaxial lesions ventral to the brainstem, 3,7,8,15,23,24,27,28,36,41,43,49,52,53,56,[59][60][61][62]64 the endonasal approach to the clival area has been used historically only to remove clival chordomas. 13,39,45,46 The bone destruction related to the chordoma often creates the surgical pathway, and its location is often purely anterior, making the transsphenoidal approach less difficult.…”

Section: Neurosurg Focus / Volume 19 / July 2005mentioning

confidence: 99%

“…As a result of these advantages it offers a lower morbidity and mortality rate when compared with transcranial procedures, and this also naturally leads to a shorter hospital stay. Nevertheless, a variety of innovative skull base approaches (including anterior, anterolateral, and posterolateral routes, which often require extensive neurovascular manipulation to gain access to the lesion) have been developed to allow resection of extraaxial lesions of the anterior skull base or lesions ventral to the brainstem 3,7,8,15,18,[20][21][22][23][24][26][27][28]36,41,43,49,52,53,56,[59][60][61][62]64 that are outside of the sella or immediate parasellar area. These approaches have often been used alone or in combination as staged approaches for extensive tumors.…”

mentioning

confidence: 99%

Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations

Cavallo

Messina²,

Cappabianca³

et al. 2005

FOC

165

190

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Object The midline skull base is an anatomical area that extends from the anterior limit of the cranial fossa down to the anterior border of the foramen magnum. Resection of lesions involving this area requires a variety of innovative skull base approaches. These include anterior, anterolateral, and posterolateral routes, performed either alone or in combination, and resection via these routes often requires extensive neurovascular manipulation. The goals in this study were to define the application of the endoscopic endonasal approach and to become more familiar with the views and skills associated with the technique by using cadaveric specimens. Methods To assess the feasibility of the endonasal route for the surgical management of lesions in the midline skull base, five fresh cadaver heads injected with colored latex were dissected using a modified endoscopic endonasal approach. Full access to the skull base and the cisternal space around it is possible with this route. From the crista galli to the spinomedullary junction, with incision of the dura mater, a complete visualization of the carotid and vertebrobasilar arterial systems and of all 12 of the cranial nerves is obtainable. Conclusions The major potential advantage of the endoscopic endonasal approach to the skull base is that it provides a direct anatomical route to the lesion without traversing any major neurovascular structures, obviating brain retraction. Many tumors grow in a medial-to-lateral direction, displacing structures laterally as they expand, creating natural corridors for their resection via an anteromedial approach. Potential disadvantages of this procedure include the relatively restricted working space and the danger of an inadequate dural repair with cerebrospinal fluid (CSF) leakage and potential for meningitis resulting. These approaches often require a large opening of the dura mater over the tuberculum sellae and posterior planum sphenoidale, or retroclival space. In addition, they typically involve large intraoperative CSF leaks, which necessitate precise and effective dural closure.

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“…With the traditional Kawase approach, a triangle was obtained at the anterior petrous apex of the area ranging from 136.71 mm 2 ). The areas and volumes obtained by MDK rhomboid exposure were 1.5 times and 2 times larger, respectively, than those obtained with the traditional Kawase approach, which was statistically significant (p < 0.001) ( Table 2).…”

Section: Results Volumetric Analysis: Dry Temporal Bonesmentioning

confidence: 99%

Quantitative analysis of the Kawase versus the modified Dolenc-Kawase approach for middle cranial fossa lesions with variable anteroposterior extension

Tripathi¹,

Deo²,

Suri³

et al. 2015

JNS

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For decades, the petrous part of the temporal bone has haunted skull base neurosurgeons and continues to do so. The depth of lesions, difficulties of approaches, and challenging neurovascular structures, e.g., brainstem and cranial nerves, have frightened neurosurgeons for decades, causing this area to have a reputation of a "No Man's Land." 17,18,22 Operative approaches to this area include clivectomy after transcervical, transoral, extended transoral, subfrontal, transsellar-transcavernous, transsylvian, combined transsylvian and anterior subtemporal, and combined transsylvian and transpetrosal approaches. Approaches vary from pure extradural to intradural and combined ones. obJect The surgical corridor to the upper third of the clivus and ventral brainstem is hindered by critical neurovascular structures, such as the cavernous sinus, petrous apex, and tentorium. The traditional Kawase approach provides a 10 × 5-mm fenestration at the petrous apex of the temporal bone between the 5th cranial nerve and internal auditory canal. Due to interindividual variability, sometimes this area proves to be insufficient as a corridor to the posterior cranial fossa. The authors describe a modification to the technique of the extradural anterior petrosectomy consisting of additional transcavernous exploration and medial mobilization of the cisternal component of the trigeminal nerve. This approach is termed the modified Dolenc-Kawase (MDK) approach. methods The authors describe a volumetric analysis of temporal bones with 3D laser scanning of dry and drilled bones for respective triangles and rhomboid areas, and they compare the difference of exposure with traditional versus modified approaches on cadaver dissection. Twelve dry temporal bones were laser scanned, and mesh-based volumetric analysis was done followed by drilling of the Kawase triangle and MDK rhomboid. Five cadaveric heads were drilled on alternate sides with both approaches for evaluation of the area exposed, surgical freedom, and angle of approach. results The MDK approach provides an approximately 1.5 times larger area and 2.0 times greater volume of bone at the anterior petrous apex compared with the Kawase's approach. Cadaver dissection objectified the technical feasibility of the MDK approach, providing nearly 1.5-2 times larger fenestration with improved view and angulation to the posterior cranial fossa. Practical application in 6 patients with different lesions proves clinical applicability of the MDK approach. coNclusioNs The larger fenestration at the petrous apex achieved with the MDK approach provides greater surgical freedom at the Dorello canal, gasserian ganglion, and prepontine area and better anteroposterior angulation than the traditional Kawase approach. Additional anterior clinoidectomy and transcavernous exposure helps in dealing with basilar artery aneurysms.

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The Petrosal Approach: Indications, Technique, and Results

Cited by 105 publications

References 5 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

Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations

Quantitative analysis of the Kawase versus the modified Dolenc-Kawase approach for middle cranial fossa lesions with variable anteroposterior extension

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