Combined Endoscopic Endonasal and Contralateral Transmaxillary Approach for Petrous Cholesteatoma: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Wei-Hsin Wang ◽  
Ming-Ying Lan ◽  
Carl H Snyderman ◽  
Paul A Gardner
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Hearing Impairment ◽  
Internal Carotid ◽  
Video Recording ◽  
Internal Auditory Canal ◽  
Petrous Apex ◽  
Endoscopic Endonasal ◽  
The Right ◽  
Key Steps

Abstract This 59-yr-old man presented with headache, dizziness, diplopia, and right-side hearing impairment for years. The objective degree of hearing impairment was not available. Magnetic resonance imaging (MRI) showed a right petrous apex lesion centered behind the right petrous internal carotid artery and extending lateral to the medial aspect of the right internal auditory canal. A combined endoscopic endonasal and left contralateral transmaxillary (CTM) approach was performed, and gross-total resection was achieved. Peeling the cyst wall from the dura resulted in minor weeping. It was covered with a left-sided, vascularized nasoseptal flap. His dizziness and diplopia improved immediately after the surgery. Histopathology revealed an epidermoid cyst. In this surgical video, we demonstrate the key steps of the CTM approach for access to the petrous apex posterior to the petrous internal carotid artery (ICA).  The patient gave informed consent for surgery and video recording.

Microsurgical Anatomy of the Endoscopy-Assisted Retrosigmoid Intradural Suprameatal Approach to the Meckel's Cave

2021 ◽  
Author(s):  
Yuanzhi Xu ◽  
Benjamin K Hendricks ◽  
Maximiliano Alberto Nunez ◽  
Ahmed Mohyeldin ◽  
Juan C Fernandez-Miranda ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Internal Auditory Canal ◽  
Semicircular Canals ◽  
Petrous Apex ◽  
Microsurgical Anatomy ◽  
Meckel’S Cave ◽  
Meckel's Cave ◽  
Trigeminal Root

Abstract BACKGROUND Understanding the microsurgical anatomical features of the endoscopy-assisted retrosigmoid intradural suprameatal approach (RISA) is critical for surgeons treating petroclival tumors or lesions in the cerebellopontine region that extend into Meckel's cave. OBJECTIVE To evaluate increased exposure for Meckel's cave in the RISA and assess the surgical landmarks for this approach. METHODS A standard retrosigmoid craniotomy to the cerebellopontine region was performed in 4 cadaveric specimens (8 hemispheres) with microscope-assisted endoscopy. The length and depth of the drilling region from the suprameatal tubercle to the petrous apex were analyzed. After opening Meckel's cave and mobilizing the trigeminal root completely, the landmarks for this approach were investigated. RESULTS The endoscopy-assisted RISA facilitates mobilization of the trigeminal root and enhances surgical exposure in the region of Meckel's cave and the petrous apex with increases of 10.1 ± 1.3 mm in depth, 21.4 ± 3.2 mm in length, and 6.4 ± 0.6 mm in height. The posterior and superior semicircular canals, internal auditory canal, superior petrous sinus, and internal carotid artery (petrous segment) served as important landmarks for this approach. One case illustration is presented to describe the application of this approach. CONCLUSION The RISA is suitable mainly for lesions in the posterior fossa that extend into Meckel's cave. The endoscopy-assisted reach optimizes accessibility to the petrous apex region, obviates the need for extensive drilling, and decreases the risk of internal carotid artery injury. Better realization and recognition of microsurgical landmarks and parameters of this approach are crucial for successful outcomes.

Paratrigeminal, Paraclival, Precavernous, or All of the Above? A Circumferential Anatomical Study of the C3-C4 Transitional Segment of the Internal Carotid Artery

2017 ◽  
Vol 14 (4) ◽  
pp. 432-440 ◽  
Author(s):  
Eleonora Marcati ◽  
Norberto Andaluz ◽  
Sebastien C Froelich ◽  
Lee A Zimmer ◽  
James L Leach ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Cavernous Sinus ◽  
Internal Carotid ◽  
Anatomical Study ◽  
Posterior Longitudinal Ligament ◽  
Petrous Apex ◽  
Meckel’S Cave ◽  
Endoscopic Endonasal ◽  
Meckel's Cave

Abstract BACKGROUND Although the term paraclival carotid pervades recent skull base literature, no clear consensus exists regarding boundaries or anatomical segments. OBJECTIVE To reconcile various internal carotid artery (ICA) nomenclatures for transcranial and endoscopic-endonasal perspectives, we reexamined the transition between lacerum (C3) and cavernous (C4) segments using a C1-C7 segments schema. In this cadaveric study, we obtained a 360°-circumferential view integrating histological, microsurgical, endoscopic, and neuroradiological analyses of this C3-C4 region and identified a distinct transitional segment. METHODS In 13 adult, silicone-injected, formalin-fixed cadaveric heads (26 sides), transcranial-extradural-subtemporal and endoscopic-endonasal CT­guided dissections were performed. A quadrilateral area was noted medial to Meckel's cave between cranial nerve VI, anterolateral and posterolateral borders of the lateral-paratrigeminal aspect of the precavernous ICA, and posterior longitudinal ligament. Endoscopically, a medial-paraclival aspect was defined. Anatomical correlations were made with histological and neuroradiological slides. RESULTS We identified a distinct precavernous C3-C4 transitional segment. In 18 (69%) specimens, venous channels were absent at the quadrilateral area, on the paratrigeminal border of the precavernous ICA. A trigeminal membrane, seen consistently on the superior border of V2, defined the lateral aspect of the cavernous sinus floor. The medial aspect of the precavernous ICA corresponded with the paraclival ICA. CONCLUSION Our study revealing the juncture of 2 complementary borders of the ICA, endoscopic endonasal (paraclival) and transcranial (paratrigeminal), reconciles various nomenclature. A precavernous segment may clarify controversies about the paraclival ICA and support the concept of a “safe door” for lesions involving Meckel's cave, cavernous sinus, and petrous apex.

scholarly journals Pseudoaneurysm of Internal Carotid Artery following Endoscopic Endonasal Pituitary Surgery requiring Endovascular Treatment in an Acromegalic Patient with a Difficult Airway

2019 ◽  
Vol 7 (01) ◽  
pp. 34-37
Author(s):  
Joanna S. Rodrigues ◽  
Ankit Gupta ◽  
Anil Parakh
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Surgical Excision ◽  
Pituitary Surgery ◽  
Lateral Part ◽  
Team Approach ◽  
Acromegalic Patient ◽  
Endoscopic Endonasal ◽  
The Right

AbstractA pituitary tumor scheduled for surgical excision can eventuate with a myriad of challenges. A 49-year-old acromegalic patient was admitted to our hospital for trans-nasal trans-sphenoidal pituitary surgery. Magnetic resonance imaging (MRI) of his brain revealed a well-defined lesion involving right half of the anterior lobe of pituitary. In the operating room, we encountered difficulty in management of the airway. The trachea could be intubated using fiberoptic bronchoscope via a proseal laryngeal mask airway after five attempts of failed intubation. Intraoperatively, the right internal carotid artery (ICA) was injured during excision of lateral part of the tumor with a blood loss of 3.5 L. Adenosine use to aid hemostasis was unsuccessful. Endovascular coil embolization was done to treat the pseudoaneurysm developed in the right ICA, to restore the blood flow. During this process, the patient developed medial rectus palsy and ptosis in the right eye, which improved gradually. The above amalgamation of maladies commanded an integrated and well-coordinated team approach to manage the catastrophic complications.

Magnetic resonance angiography follow-up examinations to detect iatrogenic pseudoaneurysms following otorhinolaryngological surgery

2007 ◽  
Vol 121 (7) ◽  
pp. 698-701 ◽  
Author(s):  
B Buerke ◽  
B Tombach ◽  
W Stoll ◽  
W Heindel ◽  
T Niederstadt
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Endovascular Coiling ◽  
Arterial Segment ◽  
Endoscopic Endonasal ◽  
Intracranial Vessel ◽  
Vessel Injury ◽  
The Right

Endoscopic endonasal surgery on a 36-year-old man was complicated by perforation of the right internal carotid artery. The immediate, substantial haemorrhage was controlled by packing the sphenoid sinus. Intra-arterial angiography of the right internal carotid artery showed small irregularities proximal to the ophthalmic artery. A follow-up examination two weeks later documented a large pseudoaneurysm in the initially irregular arterial segment, which was successfully treated by endovascular coiling.This case report illustrates the need for angiographic follow-up examinations following traumatic intracranial vessel injury in order to identify late pseudoaneurysm development.

A Road Map to the Internal Carotid Artery in Expanded Endoscopic Endonasal Approaches to the Ventral Cranial Base

2014 ◽  
Vol 10 (3) ◽  
pp. 448-471 ◽  
Author(s):  
Mohamed A. Labib ◽  
Daniel M. Prevedello ◽  
Ricardo Carrau ◽  
Edward E. Kerr ◽  
Cristian Naudy ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Carotid Bifurcation ◽  
Cranial Base ◽  
Reference Points ◽  
Petrous Apex ◽  
Endoscopic Endonasal ◽  
Carotid Canal ◽  
Road Map

Abstract BACKGROUND: Injuring the internal carotid artery (ICA) is a feared complication of endoscopic endonasal approaches. OBJECTIVE: To introduce a comprehensive ICA classification scheme pertinent to safe endoscopic endonasal cranial base surgery. METHODS: Anatomic dissections were performed in 33 cadaveric specimens (bilateral). Anatomic correlations were analyzed. RESULTS: Based on anatomic correlations, the ICA may be described as 6 distinct segments: (1) parapharyngeal (common carotid bifurcation to ICA foramen); (2) petrous (carotid canal to posterolateral aspect of foramen lacerum); (3) paraclival (posterolateral foramen lacerum to the superomedial aspect of the petrous apex); (4) parasellar (superomedial petrous apex to the proximal dural ring); (5) paraclinoid (from the proximal to the distal dural rings); and (6) intradural (distal ring to ICA bifurcation). Corresponding surgical landmarks included the Eustachian tube, the fossa of Rosenmüller, and levator veli palatini for the parapharyngeal segment; the vidian canal and V3 for the petrous segment; the fibrocartilage of foramen lacerum, foramen rotundum, maxillary strut, lingular process of the sphenoid bone, and paraclival protuberance for the paraclival segment; the sellar floor and petrous apex for the parasellar segment; and the medial and lateral opticocarotid and lateral tubercular recesses, as well as the distal osseous arch of the carotid sulcus for the paraclinoid segment. CONCLUSION: The proposed endoscopic classification outlines key anatomic reference points independent of the vessel's geometry or the sinonasal pneumatization, thus serving as (1) a practical guide to navigate the ventral cranial base while avoiding injury to the ICA and (2) further foundation for a modular access system.

scholarly journals The pterygoclival ligament: a novel landmark for localization of the internal carotid artery during the endoscopic endonasal approach

2019 ◽  
Vol 130 (5) ◽  
pp. 1699-1709 ◽  
Author(s):  
Ali Tayebi Meybodi ◽  
Andrew S. Little ◽  
Vera Vigo ◽  
Arnau Benet ◽  
Sofia Kakaizada ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Fibrous Tissue ◽  
Petrous Apex ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Pterygoid Process ◽  
The Mean

OBJECTIVEThe transpterygoid extension of the endoscopic endonasal approach provides exposure of the petrous apex, Meckel’s cave, paraclival area, and the infratemporal fossa. Safe and efficient localization of the lacerum segment of the internal carotid artery (ICA) is a crucial part of such exposure. The aim of this study is to introduce a novel landmark for localization of the lacerum ICA.METHODSTen cadaveric heads were prepared for transnasal endoscopic dissection. The floor of the sphenoid sinus was drilled to expose an extension of the pharyngobasilar fascia between the sphenoid floor and the pterygoid process (the pterygoclival ligament). Several features of the pterygoclival ligament were assessed. In addition, 31 dry skulls were studied to assess features of the bony groove harboring the pterygoclival ligament.RESULTSThe pterygoclival ligament was identified bilaterally during drilling of the sphenoid floor in all specimens. The ligament started a few millimeters posterior to the posterior end of the vomer alae and invariably extended posterolaterally and superiorly to blend into the fibrous tissue around the lacerum ICA. The mean length of the ligament was 10.5 ± 1.7 mm. The mean distance between the anterior end of the ligament and midline was 5.2 ± 1.2 mm. The mean distance between the posterior end of the ligament and midline was 12.3 ± 1.4 mm. The bony pterygoclival groove was identified at the confluence of the vomer, pterygoid process of the sphenoid, and basilar part of the occipital bone, running from posterolateral to anteromedial. The mean length of the groove was 7.7 ± 1.8 mm. Its posterolateral end faced the anteromedial aspect of the foramen lacerum medial to the posterior end of the vidian canal. A clinical case illustration is also provided.CONCLUSIONSThe pterygoclival ligament is a consistent landmark for localization of the lacerum ICA. It may be used as an adjunct or alternative to the vidian nerve to localize the ICA during endoscopic endonasal surgery.

Use of Adenosine to Facilitate Localization and Repair of Internal Carotid Artery Injury during Skull Base Surgery: A Case Report and Literature Review

2020 ◽  
pp. 000348942095637
Author(s):  
Obi I. Nwosu ◽  
Kolin E. Rubel ◽  
Mohamedkazim M. Alwani ◽  
Dhruv Sharma ◽  
Michael Miller ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Skull Base ◽  
Internal Carotid ◽  
Skull Base Surgery ◽  
Endoscopic Endonasal ◽  
Induced Hypotension ◽  
The Right ◽  
Internal Carotid Artery Injury ◽  
Neurovascular Imaging

Background: Internal carotid artery (ICA) injuries represent a rare, potentially fatal complication of endoscopic endonasal skull base surgery (EESBS). The use of adenosine to induce transient hypotension and facilitate management of high-flow, high-pressure arterial lesions has been well-documented in neuro-endovascular literature. A similar setting in which adenosine-induced hypotension may prove beneficial is during the management of major vascular injury encountered during EESBS. Methods: A case of ICA injury and subsequent repair during EESBS is presented. Results: A 74-year-old female underwent endoscopic transsphenoidal resection for a recurrent pituitary adenoma. During suprasellar resection, the right cavernous ICA was inadvertently injured resulting in brisk bleeding. Immediate vascular tamponade was applied, and a crushed muscle graft was obtained. Two intravenous doses of adenosine were administered in quick succession to produce transient hypotension and facilitate repair of the injury with the graft. Neurovascular imaging revealed a small pseudoaneurysm which remained stable throughout the postoperative course. The patient underwent definitive stent embolization of the pseudoaneurysm 1 month following discharge. Conclusion: Prompt repair of ICA injury during EESBS is crucial, but often limited by poor visualization. Adenosine-induced hypotension has demonstrated great efficacy as an adjuvant in neurovascular clipping of intracranial aneurysms and remains a valuable tool for the endoscopic skull-base surgeon as well. In cases with high risk for ICA injury, adenosine should be readily available.

Nasopharyngeal muscle patch for the management of internal carotid artery injury in endoscopic endonasal surgery

2020 ◽  
Vol 133 (5) ◽  
pp. 1382-1387 ◽  
Author(s):  
Wei-Hsin Wang ◽  
Stefan Lieber ◽  
Ming-Ying Lan ◽  
Eric W. Wang ◽  
Juan C. Fernandez-Miranda ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Skull Base ◽  
Internal Carotid ◽  
Skull Base Surgery ◽  
Management Technique ◽  
Endoscopic Endonasal Surgery ◽  
Endonasal Surgery ◽  
Endoscopic Endonasal ◽  
Muscle Graft

OBJECTIVEInjury to the internal carotid artery (ICA) is the most critical complication of endoscopic endonasal skull base surgery. Packing with a crushed muscle graft at the injury site has been an effective management technique to control bleeding without ICA sacrifice. Obtaining the muscle graft has typically required access to another surgical site, however. To address this concern, the authors investigated the application of an endonasally harvested longus capitis muscle patch for the management of ICA injury.METHODSOne colored silicone-injected anatomical specimen was dissected to replicate the surgical access to the nasopharynx and the stepwise dissection of the longus capitis muscle in the nasopharynx. Two representative cases were selected to illustrate the application of the longus capitis muscle patch and the relevance of clinical considerations.RESULTSA suitable muscle graft from the longus capitis muscle could be easily and quickly harvested during endoscopic endonasal skull base surgery. In the illustrative cases, the longus capitis muscle patch was successfully used for secondary prevention of pseudoaneurysm formation following primary bleeding control on the site of ICA injury.CONCLUSIONSNasopharyngeal harvest of a longus capitis muscle graft is a safe and practical method to manage ICA injury during endoscopic endonasal surgery.

scholarly journals Role of Extradural Clinoidectomy and Optic Unroofing in Resection of an Anterior Clinoidal Meningioma with Encasement of the Internal Carotid Artery and Its Branches

2021 ◽  
Author(s):  
Sima Sayyahmelli ◽  
Zhaoliang Sun ◽  
Emel Avci ◽  
Mustafa K. Başkaya
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Skull Base ◽  
Vision Loss ◽  
Internal Carotid ◽  
Extent Of Resection ◽  
World Health ◽  
Who Grade ◽  
The Right ◽  
Supraclinoid Internal Carotid Artery

AbstractAnterior clinoidal meningiomas (ACMs) remain a major neurosurgical challenge. The skull base techniques, including extradural clinoidectomy and optic unroofing performed at the early stage of surgery, provide advantages for improving the extent of resection, and thereby enhancing overall outcome, and particularly visual function. Additionally, when the anterior clinoidal meningiomas encase neurovascular structures, particularly the supraclinoid internal carotid artery and its branches, this further increases morbidity and decreases the extent of resection. Although it might be possible to remove the tumor from the artery wall despite complete encasement or narrowing, the decision of whether the tumor can be safely separated from the arterial wall ultimately must be made intraoperatively.The patient is a 75-year-old woman with right-sided progressive vision loss. In the neurological examination, she only had light perception in the right eye without any visual acuity or peripheral loss in the left eye. MRI showed a homogeneously enhancing right-sided anterior clinoidal mass with encasing and narrowing of the supraclinoid internal carotid artery (ICA). Computed tomography (CT) angiography showed a mild narrowing of the right supraclinoid ICA with associated a 360-degree encasement. The decision was made to proceed using a pterional approach with extradural anterior clinoidectomy and optic unroofing. The surgery and postoperative course were uneventful. MRI confirmed gross total resection (Figs. 1 and 2). The histopathology was a meningothelial meningioma, World Health Organization (WHO) grade I. The patient continues to do well without any recurrence and has shown improved vision at 15-month follow-up.This video demonstrates important steps of the microsurgical skull base techniques for resection of these challenging tumors.The link to the video can be found at https://youtu.be/vt3o1c2o8Z0

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