Tentorial Peeling: Surgical Extradural Navigation to Protect the Temporal Lobe in the Focused Combined Transpetrosal Approach

2020 ◽  
Vol 19 (5) ◽  
pp. 589-598
Author(s):  
Claudio H F Vidal ◽  
Joab A Nicácio ◽  
Yoav Hahn ◽  
Silvio S Caldas Neto ◽  
Caetano J Coimbra
Keyword(s):  
Surgical Technique ◽  
Temporal Lobe ◽  
Dura Mater ◽  
Middle Fossa ◽  
Petroclival Region ◽  
Direct Trauma ◽  
Brain Retraction ◽  
Illustrative Material

Abstract BACKGROUND Transpetrosal approaches have been used for treatment of tumors in the petroclival region for many years. Injury to the temporal lobe, however, has been a potential drawback of the techniques described to date. OBJECTIVE To describe modifications of the transpetrosal surgical technique, which allows extradural manipulation of the temporal lobe during the focused combined transpetrosal approach. This extra layer of protection avoids mechanical brain retraction, direct trauma to the temporal lobe and disruption of the local venous structures. METHODS The present manuscript describes an innovative technical nuance based on the combination of the focused combined transpetrosal approach, the peeling of the dural layers of the tentorium, and the reverse peeling of the middle fossa dura mater. Ample illustrative material is provided and illustrative cases are presented. CONCLUSION Peeling of the dural layers of the tentorium is a promising modification of the transpetrosal approach to increase the safety of the temporal lobe manipulation.

scholarly journals Anatomy of the combined retrolabyrinthine–middle fossa craniotomy

2003 ◽  
Vol 14 (6) ◽  
pp. 1-4 ◽  
Author(s):  
John S. Oghalai ◽  
Robert K. Jackler
Keyword(s):  
Surgical Technique ◽  
Middle Cranial Fossa ◽  
Nerve Function ◽  
Middle Fossa ◽  
Facial Nerve Function ◽  
Petroclival Meningiomas ◽  
Cranial Fossa ◽  
Retrolabyrinthine Approach ◽  
Brain Retraction ◽  
Gain Access

The goal of combined retrolabyrinthine–middle fossa craniotomy is to provide exposure of both the middle and posterior cranial fossae via a partial petrosectomy and division of the tentorium. Its major benefits over others are that hearing and facial nerve function are preserved and only minimal brain retraction is required. The retrolabyrinthine approach involves a presigmoid posterior fossa craniotomy that preserves the structures of the inner ear. Additionally, a middle fossa craniotomy, extending to the zygomatic root, is performed to gain access to the superior aspect of the temporal bone in the middle cranial fossa. This approach works well in cases of lesions involving the petroclival junction, including petroclival meningiomas, trigeminal schwannomas, epidermoids, and large chondrosarcomas or chordomas with intradural components. The authors describe the surgical technique of this approach.

scholarly journals Endoscope-assisted repair of CSF otorrhea and temporal lobe encephaloceles via keyhole craniotomy

2018 ◽  
Vol 128 (6) ◽  
pp. 1880-1884 ◽  
Author(s):  
Pamela C. Roehm ◽  
Derrick Tint ◽  
Norman Chan ◽  
Ryan Brewster ◽  
Vishad Sukul ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Temporal Lobe ◽  
Tertiary Care ◽  
Middle Fossa ◽  
Tertiary Care Medical Center ◽  
Lateral Skull Base ◽  
Tegmen Tympani ◽  
Brain Retraction ◽  
Keyhole Craniotomy ◽  
Cerebrospinal Fluid Otorrhea

OBJECTIVETemporal lobe encephaloceles and cerebrospinal fluid otorrhea from temporal bone defects that involve the tegmen tympani and mastoideum are generally repaired using middle fossa craniotomy, mastoidectomy, or combined approaches. Standard middle fossa craniotomy exposes patients to dural retraction, which can lead to postoperative neurological complications. Endoscopic and minimally invasive techniques have been used in other surgeries to minimize brain retraction, and so these methods were applied to repair the lateral skull base. The goal of this study was to determine if the use of endoscopic visualization through a middle fossa keyhole craniotomy could effectively repair tegmen defects.METHODSThe authors conducted a retrospective review of 6 cases of endoscope-assisted middle fossa repairs of tegmen dehiscences at a tertiary care medical center within an 18-month period.RESULTSAll cases were successfully treated using a keyhole craniotomy with endoscopic visualization and minimal retraction. Surgical times did not increase. There were no major postoperative complications, recurrences of encephaloceles, or cerebrospinal fluid otorrhea in these patients.CONCLUSIONSEndoscopic visualization allows for smaller incisions and craniotomies and less risk of brain retraction injury without compromising repair integrity during temporal encephalocele and tegmen repairs.

Temporal Lobe Changes following Middle Fossa Craniotomy: Clinical Significance

Skull Base ◽  
2008 ◽  
Vol 18 (S 01) ◽  
Author(s):  
Rick Friedman ◽  
Maroun Semaan ◽  
John Go ◽  
Marc Schwartz
Keyword(s):  
Clinical Significance ◽  
Temporal Lobe ◽  
Middle Fossa

scholarly journals Combined supra/infratentorial approach to tentorial meningiomas

2005 ◽  
Vol 63 (1) ◽  
pp. 50-54 ◽  
Author(s):  
Igor de Castro ◽  
Daniel de Holanda Christoph ◽  
José Alberto Landeiro
Keyword(s):  
Surgical Treatment ◽  
Surgical Technique ◽  
Occipital Lobe ◽  
Transverse Sinus ◽  
Surgical Removal ◽  
Tentorial Meningioma ◽  
Operative Evaluation ◽  
Unique Approach ◽  
Microsurgical Techniques ◽  
Brain Retraction

In spite of significant advancements in imaging technology, monitoring, and microsurgical techniques, complete and safe removal of tentorial meningiomas remains a challenge for most neurosurgeons. Classifications of tentorial meningiomas are revised. The combined supra/infratentorial approach to resects tentorial meningioma is discussed. This approach provides a wider exposure of the supra/infratentorial region with less brain retraction. With this approach the occipital lobe and the cerebellum are exposed along the tentorium. Two illustrative cases are presented. The patients were studied with computerized tomography, magnetic resonance and angiography. The anatomy of the transverse sinus and the confluence of the sinus could be appreciated with these studies. The operative technique is described stepwise. Emphasis is placed on pre-operative evaluation and surgical technique, leading to a total surgical removal of the lesion with margins of safety. The goal of surgical treatment of tentorial meningiomas is their complete and safe removal. With this unique approach we sought to confirm that it offers a safe means of resection not only the neoplasm but also the infiltrated dura.

A Side Door to Meckel's Cave: Anatomic Feasibility Study for the Lateral Transorbital Approach

2017 ◽  
Vol 13 (5) ◽  
pp. 614-621 ◽  
Author(s):  
Blake Harrison Priddy ◽  
Cristian Ferrareze Nunes ◽  
Andre Beer-Furlan ◽  
Ricardo Carrau ◽  
Iacopo Dallan ◽  
...  
Keyword(s):  
Skull Base ◽  
Surgical Navigation ◽  
Cranial Nerves ◽  
Anatomical Study ◽  
Middle Cranial Fossa ◽  
Middle Fossa ◽  
Meckel’S Cave ◽  
Side Door ◽  
Meckel's Cave ◽  
Brain Retraction

Abstract BACKGROUND: In the last decade, endoscopic skull base surgery has significantly developed and generated a plethora of techniques and approaches for access to the cranial ventral floor. However, the exploration for the least-aggressive, maximally efficient approach continues. OBJECTIVE: To describe in detail an anatomical study, along with the technical nuances of a novel endoscopic approach to Meckel's Cave (MC) using a lateral transorbital (LTO) route. METHODS: Eighteen orbits of injected cadaveric specimens were operated on, using an endoscopic LTO approach to MC, middle cranial fossa, and paramedian skull base preserving the orbital rim. Surgical navigation and an after-the-fact infratemporal craniectomy were utilized to identify the limits of the approach. RESULTS: Following a transorbital approach opening a trapezoid window at the superolateral aspect (average 166.7 mm2), a middle fossa “peeling” and full visualization of MC was accomplished with no difficulties in all specimens. The entire approach was performed extradurally without the need to expose the temporal lobe. CONCLUSION: In a cadaveric model, the endoscopic LTO approach affords a direct route to access MC. Its main advantage is that it is minimally disruptive in nature, less brain retraction is required, and it reaches the middle fossa in an anterolateral perspective. It also requires no manipulation of the temporalis muscle, limited cosmetic incision, and rapid recovery. It seems a viable alternative to traditional approaches for lesions lateral to the cranial nerves at the cavernous sinus and MC, that is, schwannomas. Clinical utilization of this approach will challenge its efficacy and identify limitations.

Zygomaticotemporal Approach to the Basis Cranii and Basilar Artery

Neurosurgery ◽  
1988 ◽  
Vol 23 (1) ◽  
pp. 20-22 ◽  
Author(s):  
Glenn Neil-Dwyer ◽  
Michael Sharr ◽  
Richard Haskell ◽  
David Currie ◽  
Massoud Hosseini
Keyword(s):  
Temporal Lobe ◽  
Basilar Artery ◽  
Masseter Muscle ◽  
Anterior Approach ◽  
Zygomatic Bone ◽  
Interpeduncular Cistern ◽  
Suprasellar Region ◽  
Brain Retraction

ABSTRACT When using the zygomaticotemporal approach, one removes the whole of the zygomatic bone with its attachment to the masseter muscle, allowing a lower and more anterior approach to the interpeduncular cistern along the inferomedial surface of the temporal lobe. Minimal brain retraction is required to give an excellent view of the bifurcation of the basilar artery and of the suprasellar region. (Neurosurgery 23:20-22, 1988)

Endoscopic Transorbital Approach to Mesial Temporal Lobe for Intra-Axial Lesions: Cadaveric Study and Case Series (SevEN-008)

2021 ◽  
Author(s):  
Hun Ho Park ◽  
Tae Hoon Roh ◽  
Seonah Choi ◽  
Jihwan Yoo ◽  
Woo Hyun Kim ◽  
...  
Keyword(s):  
Temporal Lobe ◽  
Case Series ◽  
Invasive Technique ◽  
Low Grade ◽  
Orbital Roof ◽  
Endoscopic Transorbital ◽  
Temporal Horn ◽  
Skull Base Lesions ◽  
Mesial Temporal Lobe ◽  
Brain Retraction

Abstract BACKGROUND Endoscopic transorbital approach (ETOA) has been proposed as a minimally invasive technique for the treatment of skull base lesions located around mesial temporal lobe (MTL), mostly extra-axial pathology. OBJECTIVE To explore the feasibility of ETOA in accessing intraparenchymal MTL with cadaveric specimens and describe our initial clinical experience of ETOA for intra-axial lesions in MTL. METHODS Anatomic dissections were performed in 4 adult cadaveric heads using a 0° endoscope. First, a stepwise anatomical investigation of ETOA to intraparenchymal MTL was explored. Then, ETOA was applied clinically for 7 patients with intra-axial lesions in MTL, predominantly high-grade gliomas (HGGs) and low-grade gliomas (LGGs). RESULTS The extradural stage of ETOA entailed a superior eyelid incision followed by orbital retraction, drilling of orbital roof, greater and lesser wing of sphenoid bone, and cutting of the meningo-orbital band. For the intradural stage, the brain tissue medial to the occipito-temporal gyrus was aspirated until the temporal horn was opened. The structures of MTL could be aspirated selectively in a subpial manner without injury to the neurovascular structures of the ambient and sylvian cisterns, and the lateral neocortex. After cadaveric validation, ETOA was successfully performed for 4 patients with HGGs and 3 patients with LGGs. Gross total resection was achieved in 6 patients (85.7%) without significant surgical morbidities including visual field deficits. CONCLUSION ETOA provides a logical line of access for intra-axial lesions in MTL. The safe and natural surgical trajectory of ETOA can spare brain retraction, neurovascular injury, and disruption of the lateral neocortex.

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.

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