Commentary: Dissection of the Petrosal Presigmoid-Retrolabyrinthine Approach for the Petroclival Region on a Cadaver: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (4) ◽  
pp. E400-E401
Author(s):  
Daniel G Eichberg ◽  
Ricardo J Komotar ◽  
Michael E Ivan
Keyword(s):  
Petroclival Region ◽  
Retrolabyrinthine Approach

Partial Labyrinthectomy Petrous Apicectomy Approach to the Petroclival Region: An Anatomic and Technical Study

Neurosurgery ◽  
2002 ◽  
Vol 51 (1) ◽  
pp. 147-160 ◽  
Author(s):  
Amitabha Chanda ◽  
Anil Nanda
Keyword(s):  
Cranial Nerves ◽  
Jugular Bulb ◽  
Microsurgical Anatomy ◽  
Petroclival Region ◽  
High Jugular Bulb ◽  
Before And After ◽  
Inaccessible Area ◽  
Retrolabyrinthine Approach ◽  
Brain Retraction ◽  
Partial Labyrinthectomy

Abstract OBJECTIVE The petroclival region generally is thought to be an inaccessible area in the intracranial compartment. A number of ways of reaching this area during surgery have been described, including the presigmoid petrosal approach. The partial labyrinthectomy petrous apicectomy approach is a relatively new approach to this region and is a variant of the presigmoid petrosal approach. This study aims to demonstrate the technique and the microsurgical anatomy of the partial labyrinthectomy petrous apicectomy approach and to provide a quantitative study of its exposure to compare it with other common approaches to this region, particularly the presigmoid petrosal approach. METHODS Bilateral stepwise dissections were performed on 15 formalin-fixed and dye-injected cadaveric heads (30 sides) under ×3 to ×40 magnification. A temporal craniotomy was performed after a complete mastoidectomy. A partial labyrinthectomy and petrous apicectomy were performed next. The amount of dura exposed was measured before and after the partial labyrinthectomy and the petrous apicectomy. By measuring the angles of exposure, the approach was examined to analyze how much increased access was gained. RESULTS This approach provided wide exposure to the petroclival region, the cerebellopontine angle, Meckel's cave, the cavernous sinus, and the prepontine region. On average, there was an increase of 10.8 mm in horizontal exposure as compared with the retrolabyrinthine approach. The average angle of vision achieved with the clival pit as the target was 58.9 degrees. In most of the specimens, an area from the IIIrd to the IXth cranial nerves was easily visible without any significant brain retraction. A high jugular bulb did not reduce the exposure. CONCLUSION The partial labyrinthectomy petrous apicectomy approach converts two narrow tunnels into a wide corridor. It increases the angle of exposure markedly, providing easy and excellent exposure of the otherwise difficult-to-access petroclival region, and it may also preserve hearing.

scholarly journals Study of comparative surgical exposure to the petroclival region using patient-specific, petroclival meningioma virtual reality models

2021 ◽  
Vol 51 (2) ◽  
pp. E13
Author(s):  
Walter C. Jean ◽  
Yang Yang ◽  
Aneil Srivastava ◽  
Alexander X. Tai ◽  
Aalap Herur-Raman ◽  
...  
Keyword(s):  
Virtual Reality ◽  
Tumor Volume ◽  
Surgical Techniques ◽  
Patient Specific ◽  
Surgical Approaches ◽  
Imaging Data ◽  
Petroclival Region ◽  
Petroclival Meningiomas ◽  
Retrolabyrinthine Approach ◽  
Ct And Mri

OBJECTIVE Despite advancement of surgical techniques, the attachments of petroclival meningiomas near the central clival depression (CCD) remain difficult to visualize. With existing methods, the amount of tumor near the CCD that is inaccessible through various approaches cannot be compared. Tumors distort the brainstem, changing the size of the operative corridor for some but not all approaches; therefore, using cadavers with normal posterior fossae makes it impossible to compare different approaches to the tumor. The authors used virtual reality (VR) models created from the imaging data of patients to compare various surgical approaches that have otherwise been incomparable in previous studies. METHODS CT and MRI data obtained in 15 patients with petroclival meningiomas were used to create anatomically accurate 3D VR models. For each model, various surgical approaches were performed, and the surgical freedom to 6 targets of the regions were measured. Furthermore, portions of the tumor that were visually blocked by the brainstem or bony structures were segmented and recorded as blinded volumes for comparison. RESULTS The extended retrosigmoid approach generated excellent exposure of the petroclival region, but for most specimens, there was inaccessible tumor volume adjacent to the brainstem (mean 641.3 mm3, SE 161.8). In contrast, the brainstem sides of the tumors were well-visualized by all the transpetrosal approaches. The blinded volume of the tumor was largest for the retrolabyrinthine approach, and this was statistically significant compared with all other approaches (mean 2381.3 mm3, SE 185.4). CONCLUSIONS The authors performed a novel laboratory study by using patient CT and MRI data to generate 3D virtual models to compare surgical approaches. Since it is impossible to perform various approaches in separate surgeries in patients for comparison, VR represents a viable alternative for such comparative investigations.

Classification and quantification of the petrosal approach to the petroclival region

2000 ◽  
Vol 93 (1) ◽  
pp. 108-112 ◽  
Author(s):  
Michael A. Horgan ◽  
Gregory J. Anderson ◽  
Jordi X. Kellogg ◽  
Marc S. Schwartz ◽  
Sergey Spektor ◽  
...  
Keyword(s):  
Content Type ◽  
Petroclival Region ◽  
Nerve Preservation ◽  
Systematic Assessment ◽  
Central Target ◽  
Stereotactic Guidance ◽  
Transcrusal Approach ◽  
Retrolabyrinthine Approach ◽  
Partial Labyrinthectomy ◽  
Fine Print

Object. The petrosal approach to the petroclival region has been used by a variety of authors in various ways and the terminology has become quite confusing. A systematic assessment of the benefits and limitations of each approach is also lacking. The authors classify their approach to the middle and upper clivus, review the applications for each, and test their hypotheses on a cadaver model by using frameless stereotactic guidance.Methods. The petrosal approach to the upper and middle clivus is divided into four increasingly morbidity-producing steps: retrolabyrinthine, transcrusal (partial labyrinthectomy), transotic, and transcochlear approaches. Four latexinjected cadaveric heads (eight sides) underwent dissection in which frameless stereotactic guidance was used. An area of exposure 10 cm superficial to a central target (working area) was calculated. The area and length of clival exposure with each subsequent dissection was also calculated.The retrolabyrinthine approach spares hearing and facial function but provides for only a small window of upper clival exposure. The view afforded by what we have called the transcrusal approach provides for up to four times this exposure. The transotic and transcochlear procedures, although producing more morbidity, add little in terms of a larger clival window. However, with each step, the surgical freedom for manipulation of instruments increases.Conclusions. The petrosal approach to the upper and middle clivus is useful but should be used judiciously, because levels of morbidity can be high. The retrolabyrinthine approach has limited utility. For tumors without bone invasion, the transcrusal approach provides a much more versatile exposure with an excellent chance of hearing and facial nerve preservation. The transotic approach provides for greater versatility in treating lesions but clival exposure is not greatly enhanced. Transcochlear exposure adds little in terms of intradural exposure and should be reserved for cases in which access to the petrous carotid artery is necessary.

The Widened Retrolabyrinthine Approach in the Management of Vestibular Schwannoma

Skull Base ◽  
2007 ◽  
Vol 17 (S 1) ◽  
Author(s):  
Vincent Darrouzet ◽  
Valérie Franco-Vidal ◽  
Dominique Liguoro
Keyword(s):  
Vestibular Schwannoma ◽  
Retrolabyrinthine Approach

Surgical Management of Petroclival Meningiomas: Defining Resection Goals Based on Risk of Neurological Morbidity and Tumor Recurrence Rates in 137 Patients

Neurosurgery ◽  
2005 ◽  
Vol 56 (3) ◽  
pp. 546-559 ◽  
Author(s):  
Kenneth M. Little ◽  
Allan H. Friedman ◽  
John H. Sampson ◽  
Masahiko Wanibuchi ◽  
Takanori Fukushima
Keyword(s):  
Cranial Nerve ◽  
Tumor Recurrence ◽  
Critical Role ◽  
Recurrence Rates ◽  
Total Resection ◽  
Petroclival Region ◽  
Petroclival Meningiomas ◽  
Increased Risk ◽  
Neurological Morbidity

Abstract OBJECTIVE: Meningiomas arising from the petroclival region remain a challenging surgical problem. Because of the substantial risk of neurological morbidity, uniformly pursuing a gross total resection (GTR) to minimize tumor recurrence rates may not be justified. We sought to define optimal resection goals based on risk factors for postoperative neurological morbidity and tumor recurrence rates. METHODS: This series represents our experience with 137 meningiomas arising from the petroclival region resected between June 1993 and October 2002. There were 38 male and 99 female patients with a mean age of 53 years. RESULTS: GTR was achieved in 40% of patients, and near total resection (NTR) was achieved in 40% of patients. One operative death occurred. Twenty-six percent of patients experienced new postoperative cranial nerve deficits, paresis, or ataxia when assessed at a mean follow-up of 8.3 months. The risk of cranial nerve deficits increased with prior resection (P < 0.001), preoperative cranial nerve deficit (P = 0.005), tumor adherence to neurovascular structures (P = 0.046), and fibrous tumor consistency (P = 0.005). The risk of paresis or ataxia increased with prior resection (P = 0.001) and tumor adherence (P = 0.045). Selective NTR rather than GTR in patients with adherent or fibrous tumors significantly reduced the rate of neurological deficits. Radiographic recurrence or progression occurred in 17.6% of patients at a mean follow-up of 29.8 months. Tumor recurrence rates after GTR and NTR did not differ significantly (P = 0.111). CONCLUSION: Intraoperatively defined tumor characteristics played a critical role in identifying the subset of patients with an increased risk of postoperative deficits. By selectively pursuing an NTR rather than a GTR, neurological morbidity was reduced significantly without significantly increasing the rate of tumor recurrence.

scholarly journals The Retrolabyrinthine Approach and Vascular Loop

1989 ◽  
Vol 99 (10) ◽  
pp. 1035???1039 ◽  
Author(s):  
Richard J. Wiet ◽  
David R. Schramm ◽  
Robert P. Kazan
Keyword(s):  
Retrolabyrinthine Approach ◽  
Vascular Loop

Retrosigmoid transhorizontal fissure approach to lateral pontine cavernous malformation: comparison to transpetrosal presigmoid retrolabyrinthine approach

2021 ◽  
pp. 1-10
Author(s):  
Julia R. Schneider ◽  
Amrit K. Chiluwal ◽  
Mohsen Nouri ◽  
Giyarpuram N. Prashant ◽  
Amir R. Dehdashti
Keyword(s):  
Operative Time ◽  
Cavernous Malformation ◽  
Similar Efficacy ◽  
Middle Cerebellar Peduncle ◽  
Entry Zone ◽  
Cadaveric Dissection ◽  
Cerebellar Peduncle ◽  
Retrolabyrinthine Approach ◽  
Brainstem Cavernous Malformation

OBJECTIVE The retrosigmoid (RS) approach is a classic route used to access deep-seated brainstem cavernous malformation (CM). The angle of access is limited, so alternatives such as the transpetrosal presigmoid retrolabyrinthine (TPPR) approach have been used to overcome this limitation. Here, the authors evaluated a modification to the RS approach, horizontal fissure dissection by using the RS transhorizontal (RSTH) approach. METHODS Relevant clinical parameters were evaluated in 9 patients who underwent resection of lateral pontine CM. Cadaveric dissection was performed to compare the TPPR approach and the RSTH approach. RESULTS Five patients underwent the TPPR approach, and 4 underwent the RSTH approach. Dissection of the horizontal fissure allowed for access to the infratrigeminal safe entry zone, with a direct trajectory to the middle cerebellar peduncle similar to that used in TPPR exposure. Operative time was longer in the TPPR group. All patients had a modified Rankin Scale score ≤ 2 at the last follow-up. Cadaveric dissection confirmed increased anteroposterior working angle and middle cerebellar peduncle exposure with the addition of horizontal fissure dissection. CONCLUSIONS The RSTH approach leads to a direct lateral path to lateral pontine CM, with similar efficacy and shorter operative time compared with more extensive skull base exposure. The RSTH approach could be considered a valid alternative for resection of selected pontine CM.

Endoscopically Assisted Drilling, Exposure of the Fundus through a Presigmoid Retrolabyrinthine Approach: A Cadaveric Feasibility Study

2017 ◽  
Vol 158 (1) ◽  
pp. 155-157 ◽  
Author(s):  
Thomas Muelleman ◽  
Matthew Shew ◽  
Sameer Alvi ◽  
Kushal Shah ◽  
Hinrich Staecker ◽  
...  
Keyword(s):  
Temporal Bone ◽  
Feasibility Study ◽  
Cerebellopontine Angle ◽  
Internal Auditory Canal ◽  
Entire Length ◽  
Retrolabyrinthine Approach

The presigmoid retrolabyrinthine approach to the cerebellopontine angle is traditionally described to not provide access to the internal auditory canal (IAC). We aimed to evaluate the extent of the IAC that could be exposed with endoscopically assisted drilling and to measure the percentage of the IAC that could be visualized with the microscope and various endoscopes after drilling had been completed. Presigmoid retrolabyrinthine approaches were performed bilaterally on 4 fresh cadaveric heads. We performed endoscopically assisted drilling to expose the fundus of the IAC, which resulted in exposure of the entire IAC in 8 of 8 temporal bone specimens. The microscope afforded a mean view of 83% (n = 8) of the IAC. The 0°, 30°, 45°, and 70° endoscope each afforded a view of 100% of the IAC in 8 of 8 temporal bone specimens. In conclusion, endoscopic drilling of the IAC of can provide an extradural means of exposing the entire length of the IAC while preserving the labyrinth.

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