Transcavernous approach to diseases of the anterior upper third of the posterior fossa

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The region in the upper anterior third of the posterior fossa is a surgically hidden, narrow corridor between the petroclival surface anteriorly and the surface of the brainstem posteriorly. Although several approaches have been described to help surgeons reach this region, few of them enable practitioners to reach the different corners of the area and provide as wide a view as the one achieved using the transcavernous route.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A transcavernous approach was used in 91 cases (50 complex upper basilar artery [BA] aneurysms, 30 upper petroclival junction meningiomas, five trigeminal nerve schwannomas, three upper clival chordomas, and three anterior pontine lesions) involving the anterior upper third of the posterior fossa. The approach uses the pretemporal route with exposure of the lateral wall of the cavernous sinus. It entails removal of the anterior clinoid process. The posterior clinoid process is also removed when necessary. The approach leads to the upper basilar region. It is widened inferiorly to expose the anterior aspect by removal of the posterior clinoid process and the petroclival osseous and dural elements. Its lateral extension exposes the region of the Meckel cave and it can be widened by removal of the petrous apex.</jats:p> <jats:p>Seventy patients experienced new transient mild cranial neuropathies, 67 of whom recovered fully. Surgically related ischemic morbidities occurred in three patients with BA aneurysms (one small medial thalamic infarct, ataxia due to superior cerebellar artery ischemia, and distal middle cerebral artery embolus in a patient with atrial fibrillation in whom anticoagulation therapy was stopped). All the neuropathies in patients with BA aneurysms were oculomotor and recovery was the rule in all of them. Three new permanent cranial neuropathies occurred in the patients with meningiomas. In seven patients with preoperative neuropathy, two had partial improvement. Five patients with atypical meningiomas were treated with postoperative radiation therapy. Progression occurred later in four patients who were treated with gamma knife surgery. There were no surgery-related deaths. More than 1 year of follow-up data were available in 85 patients, and 94% of those patients were in an active and functional state (Glasgow Outcome Scale scores of 4 and 5).</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The safety achieved with the transcavernous route allows surgeons to achieve wide exposures to lesions involving the anterior upper third of the posterior fossa. It is an approach that should be mastered by every neurosurgeon dealing with cranial lesions.</jats:p></jats:sec>

Nasal cavity-maxillary sinus-pterygopalatine fossa-Meckel’s cave: a preliminary anatomic study of an endoscopy-based operative approach

“…The anterolateral approach relies on the pterion region as an entry point to access Meckel's cave [5,[14][15][16][17] . To reach the anterior part of the medial component of Meckel's cave, the anteromedial and the anterolateral triangles of the middle cranial fossa need to be traversed [15,17,18] .…”

“…To reach the anterior part of the medial component of Meckel's cave, the anteromedial and the anterolateral triangles of the middle cranial fossa need to be traversed [15,17,18] . This approach is applied mainly to remove the intracranial trigeminal schwannomas (TS) predominantly located in the middle fossa.…”

The Avoidance of Microsurgical Complications in the Extradural Anterior Clinoidectomy to Paraclinoid Aneurysms

“…All paraclinoid aneurysms were confirmed using digital subtraction angiography (DSA), three-dimensional computed tomography angiography (CTA), preoperative temporal bone computed tomography (CT), and magnetic resonance imaging (MRI) (in 12 of the patients). Microsurgery was performed via an ipsilateral pterional craniotomy and with an extradural, extended anterior clinoidectomy 8,16,24,35) . We retrospectively reviewed the patients' medical charts, office records, radiographic studies, operative records, and videos.…”

“…However, advances in skull base approaches 10,11) , especially the extradural anterior clinoidectomy 8,16,24) , have greatly improved surgical outcomes for patients with paraclinoid aneurysms. Furthermore, endovascular procedures have become alternative treatments for paraclinoid aneurysms 17,27,31) .…”

Surgery for a Case of Three-Compartment Trigeminal Schwannoma : Technical Aspects

“…At the caudal end of the Gasserian ganglion, the arachnoid pouch is expanded conforming the dural pouch and made the trigeminal cistern 15) . The plane between the outer dural and inner epineural layer of the lateral wall of the cavernous sinus is extended over the dural pouch of the Meckel's cave and fused at porous trigeminus under the free edge of tentorium 8) . The opening of Meckel's cave is most efficient when the dura was cut from brain stem side to the periphery along the superolateral margin of the trigeminal root.…”