scholarly journals Transcondylar Approach for Resection of Medullary Cavernous Malformation: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Kadir Erkmen ◽  
Ossama Al-Mefty
Keyword(s):  
Cranial Nerves ◽  
Poor Response ◽  
High Rate ◽  
Neurological Deficits ◽  
Sensory Loss ◽  
Neurophysiological Monitoring ◽  
Cavernous Malformations ◽  
Transcondylar Approach ◽  
Facial Numbness ◽  
Lower Cranial Nerves

Abstract Cavernous malformations located within the brainstem present with a high rate of neurological symptoms and carry a more aggressive course in both pediatric and adult populations.1,2 Cavernomas within the medulla are the rarest form, representing only 5% of all brainstem lesions.3 Repeated hemorrhage of brainstem cavernomas is associated with significant and cumulative neurological deficits and thus requires treatment.4 Microsurgical resection has become the optimal mode of treatment with the aim of resecting the live malformation and not merely the multiaged, organized hematoma.4 This is best achieved by approaching the cavernoma at the location where it projects to the surface and entering the lesion through a safe brainstem anatomic zone. For ventrally located lesions in the medulla, a transcondylar skull base approach provides a direct trajectory to the entry zone through a short surgical distance without the need to manipulate or retract neurovascular structures.5-8 Neuronavigation and intraoperative neurophysiological monitoring of somatosensory evoked potential, motor, and lower cranial nerves are adjuncts to increase patient safety. Radiosurgery for the treatment of brainstem cavernous malformations has been proposed; however, it demonstrates high risk and variable and often poor response rates.9 We present a surgical video demonstrating the transcondylar approach and resection of a medullary cavernoma in a 54-yr-old woman who has had multiple known prior hemorrhages and presented with a new onset of facial numbness and weakness, ataxia, and left body sensory loss. The patient consented to surgery and to photograph publication.  Images at 1:28, 1:43 (left), 2:02 from Al-Mefty O, Operative Atlas of Meningiomas, © LWW, 1997,5 with permission.  Images at 1:43 (right) from Arnautovic et al,8 with permission from JNSPG.

scholarly journals Complex tumors of the glomus jugulare: criteria, treatment, and outcome

2004 ◽  
Vol 17 (2) ◽  
pp. 1356-1366
Author(s):  
Ossama Al-Mefty ◽  
Aramis Teixeira
Keyword(s):  
Malignant Tumor ◽  
Cranial Nerve ◽  
Treatment Plan ◽  
Cranial Nerves ◽  
Neurological Deficits ◽  
Adrenal Tumors ◽  
Glomus Jugulare ◽  
Associated Lesions ◽  
Vertebrobasilar Artery ◽  
Lower Cranial Nerves

Object Tumors of the glomus jugulare are benign, slow-growing paragangliomas. Their natural history, surgical treatment, and outcome have been well addressed in the recent literature; however, there remains a subgroup of complex tumors—multiple, giant, malignant, neuropeptide-secreting lesions, and those treated previously by an intervention with an adverse outcome—that is high risk, presents surgical challenges, and is associated with treatment controversy. In this article the authors report on a series of patients with complex glomus jugulare tumors and focus on treatment decisions, avoidance of complications, surgical refinements, and patient outcomes. Methods In this retrospective study, the patient population was composed of 11 male and 32 female patients (mean age 47 years) with complex tumors of the glomus jugulare who were treated by the senior author within the past 20 years. These include 38 patients with giant tumors, 11 with multiple paragangliomas (seven bilateral and four ipsilateral), two with tumors that hypersecreted catecholamine, and one with a malignant tumor. Six patients had associated lesions: one dural arteriovenous malformation, one carotid artery (CA) aneurysm, two adrenal tumors, and two other cranial tumors. All but one patient presented with neurological deficits. Cranial nerve deficits, particularly those associated with the lower cranial nerves, were the prominent feature. Twenty-eight patients underwent resection in an attempt at total removal, and gross-total resection was achieved in 24 patients. Particularly challenging were cases in which the patient had undergone prior embolization or CA occlusion, after which new feeding vessels from the internal CA and vertebrobasilar artery circulation developed. The surgical technique was tailored to each patient and each tumor. It was modified to preserve facial nerve function, particularly in patients with bilateral tumors. Intrabulbar dissection was performed to increase the likelihood that the lower cranial nerves would be preserved. Each tumor was isolated to improve its resectability and prevent blood loss. No operative mortality occurred. In one patient hemiplegia developed postoperatively due to CA thrombosis, but the patient recovered after an endovascular injection of urokinase. In four patients a cerebrospinal fluid leak was treated through spinal drainage, and in five patients infection developed in the external ear canal. Two of these infections progressed to osteomyelitis of the temporal bone. There were two recurrences, one in a patient with a malignant tumor who eventually died of the disease. Conclusions Despite the challenges encountered in treating complex glomus jugulare tumors, resection is indicated and successful. Multiple tumors mandate a treatment plan that addresses the risk of bilateral cranial nerve deficits. The intra-bulbar dissection technique can be used with any tumor, as long as the tumor itself has not penetrated the wall of the jugular bulb or infiltrated the cranial nerves. Tumors that hypersecrete catecholamine require perioperative management and malignant tumors carry a poor prognosis.

Partial Transcondylar Approach for Ventral Foramen Magnum Neurenteric Cyst: 2-Dimensional Operative Video

2018 ◽  
Vol 16 (3) ◽  
pp. E81-E81
Author(s):  
Ken Matsushima ◽  
Michihiro Kohno ◽  
Hitoshi Izawa ◽  
Yujiro Tanaka
Keyword(s):  
Cranial Nerves ◽  
Three Dimensional ◽  
Posterior Part ◽  
Foramen Magnum ◽  
Neurological Deficits ◽  
Cystic Tumor ◽  
Occipital Condyle ◽  
Neurenteric Cyst ◽  
Posterior Arch ◽  
Transcondylar Approach

Abstract The anterior foramen magnum area, ventral to the brainstem is one of the most difficult regions to access surgically, and the extent of osseous drilling through the far-lateral or transcondylar approach should be planned in each case based on the tumor extension.1,2 This video, reproduced after informed consent of the patient, demonstrates a case of a ventral foramen magnum neurenteric cyst surgically treated using the partial transcondylar approach. A 27-yr-old woman presented with gait disturbance, oscillopsia, and transient arm numbness. Neuroimaging revealed a ventral foramen magnum cystic tumor involving the basilar and bilateral vertebral arteries. The tumor extended inferiorly from the middle clivus to the C1 level, and occupied the whole premedullary cistern compressing the bilateral lower cranial nerves. The left partial transcondylar approach was performed with drilling the condylar fossa, superior part of the occipital condyle, C1 posterior arch, and posterior part of the jugular process to achieve the sufficient surgical view from the inferolateral side. The drilling of the occipital condyle was minimized so that the articular facet of the occipital condyle was preserved. The tumor on the bilateral side was completely removed as enabled by the sufficient surgical field without new neurological deficits. Three-dimensional reconstructed images based on the postoperative computed tomography scans demonstrated the appropriate extent of the osseous drilling.

The transcondylar approach to extradural nonneoplastic lesions of the craniovertebral junction

1996 ◽  
Vol 84 (1) ◽  
pp. 1-6 ◽  
Author(s):  
Ossama Al-Mefty ◽  
Luis A. B. Borba ◽  
Nobuo Aoki ◽  
Edgardo Angtuaco ◽  
T. Glenn Pait
Keyword(s):  
Cranial Nerves ◽  
Craniovertebral Junction ◽  
Craniocervical Junction ◽  
Direct Visualization ◽  
Occipitocervical Fusion ◽  
Content Type ◽  
Transcondylar Approach ◽  
Dural Sac ◽  
Lower Cranial Nerves ◽  
And Control

✓ Ventral extradural lesions at the craniovertebral junction are commonly exposed through the transoral or transmaxillary approach. The disadvantages of these approaches include: 1) difficulty in reaching laterally located lesions; 2) ineligibility of patients with an intradental distance of less than 25 mm or severe macroglossia; 3) the need for a separate procedure for stabilization and fusion; and 4) the risk of infection from transgressing a contaminated field. In this report, the authors describe the use of the transcondylar approach to extradural nonneoplastic lesions of the anterior craniovertebral junction for decompression and stabilization. Advantages of this approach include: 1) a short distance to the lesion; 2) a wide surgical envelope; 3) direct visualization of the dural sac, eliminating manipulation of the brainstem or upper spinal cord; 4) easy identification and control of the ipsilateral vertebral artery; 5) direct visualization and preservation of the lower cranial nerves; and 6) a sterile field. In addition, occipitocervical fusion and instrumentation can be performed during the same procedure. The transcondylar approach, based on anatomical studies in cadavers, was used to treat eight patients with ventral nonneoplastic lesions at the craniocervical junction. The technique and results are described.

scholarly journals Endoscopic endonasal approach for clipping of a PICA aneurysm

2020 ◽  
Vol 2 (2) ◽  
pp. V14
Author(s):  
Ezequiel Goldschmidt ◽  
Philippe Lavigne ◽  
Carl Snyderman ◽  
Paul A. Gardner
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Neurological Deficits ◽  
Csf Leak ◽  
Open Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Posthemorrhagic Hydrocephalus ◽  
Cerebellar Artery ◽  
Lower Cranial Nerves

This video depicts the case of a 59-year-old woman that presented to the emergency department with the worst headache of her life. CT showed subarachnoid hemorrhage and digital subtraction angiogram demonstrated a right-side posterior inferior cerebellar artery (PICA) aneurysm. Given the medial and ventral position of the aneurysm, deep to the lower cranial nerves, which obviated distal control from an open approach, and the absence of an endovascular option able to reliably preserve the PICA, an endonasal approach was offered. A far medial approach was performed, and the aneurysm was successfully clipped. The patient developed a postoperative CSF leak with persistent posthemorrhagic hydrocephalus treated with reexploration and an eventual ventriculoperitoneal shunt. The patient was discharged without neurological deficits.The video can be found here: https://youtu.be/_9hsM2CaMow.

The investigation and management of petrous apex ersion

1985 ◽  
Vol 99 (5) ◽  
pp. 439-450 ◽  
Author(s):  
L. M. Flood ◽  
J. L. Kemink ◽  
M. D. Graham
Keyword(s):  
Temporal Bone ◽  
Cranial Nerves ◽  
Internal Auditory Canal ◽  
Jugular Foramen ◽  
Petrous Apex ◽  
Unique Challenge ◽  
Anterior Extension ◽  
Facial Numbness ◽  
Lower Cranial Nerves ◽  
Ear Effusion

AbstractDisease of the apex of the petrous temporal bone, while rarely encountered, can present a unique challenge to the otologist. Lesions tend to be advanced at presentation, as massive bony erosion can remain asymptomatic. When symptoms occur, they reflect involvement of the neurovascular contents of the temporal bone. The earliest clinical features, such as headache, facial numbness and middle-ear effusion, do not immediately suggest the site or gravity of the underlying pathology. Anterior extension of disease may produce ophthalmoplegia and diplopia whilst posterior spread involves the lower cranial nerves, within the internal auditory canal, jugular foramen and hypoglossal canal.

scholarly journals Foramen Magnum Meningioma—The Attainment of the Intra-Arachnoidal Dissection: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Walid Ibn Essayed ◽  
Emad Aboud ◽  
Ossama Al-Mefty
Keyword(s):  
Surgical Intervention ◽  
Treatment Plan ◽  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Neurophysiological Monitoring ◽  
Cerebellar Artery ◽  
Swallowing Difficulties ◽  
Body Level ◽  
Lower Cranial Nerves

Abstract Ventral foramen magnum meningiomas are a forbidding lesion. The stake is so high with a risk of devastating paralysis and respiratory failure. Careful preoperative clinical and radiological evaluation is necessary to implement the best treatment plan. Successful surgical intervention depends on paying high attention to minute details throughout the case, from intratracheal intubation to extubation. The neural head-on-neck position is critical to avoid further medullary compression at intubation and positioning.1 Extensive neurophysiological monitoring, including somatosensory, motor, brainstem evoked potential, and cranial nerves, during the positioning and throughout the case, is extremely helpful to detect early signs of dysfunction.1 To expose and access ventral tumors, partial condyle resection and vertebral artery transposition are invaluable techniques.2,3 Preservation and minute manipulation of the vital neurovascular structures at this junction that includes the medullar, anterior spinal artery, posterior inferior cerebellar artery, vertebral junction perforators, and lower cranial nerves are essential for good outcomes. This is achieved by microsurgical intra-arachnoidal dissection under high magnification and after debulking the tumor to establish that plane.1,3,4 The demonstration of this technique is the purpose of this article. We demonstrate these surgical tenets applied to the resection of a large ventral foramen magnum meningioma extending from the midclivus to the C3 vertebral body level in a 54-yr-old female presenting with swallowing difficulties. The patient consented to the surgical intervention and the publication of her images. Image at 1:38 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, © LWW, 1998.

Calcified Extra-axial Cavernoma Involving Lower Cranial Nerves: Technical Case Report

2009 ◽  
Vol 64 (suppl_1) ◽  
pp. ONSE135-ONSE136 ◽  
Author(s):  
Alessio Albanese ◽  
Carmelo L. Sturiale ◽  
Quintino G. D’Alessandris ◽  
Gennaro Capone ◽  
Giulio Maira
Keyword(s):  
Histopathological Examination ◽  
Vascular Malformations ◽  
Cranial Nerves ◽  
Neurological Deficits ◽  
Radiological Appearance ◽  
History Of ◽  
Tone Of Voice ◽  
Risk Of Hemorrhage ◽  
Lower Cranial Nerves ◽  
Gait Disturbances

Abstract Objective: Extra-axial cavernomas involving cranial nerves (CNs) are uncommon vascular malformations and may cause neurological deficits. We report what is, to our knowledge, a unique case of a calcified extra-axial cerebellopontine angle (CPA) cavernoma involving the lower CNs. Clinical Presentation: A 48-year-old man was admitted to our department with a 5-month history of gait instability and loss in tone of voice. A clinical examination documented gait disturbances and hoarseness but was otherwise unremarkable. Neuroradiological studies revealed a calcified mass in the lower third of the CPA cistern that was angiographically occult. It was associated with 3 additional lesions with a radiological appearance suggestive of multiple cavernomas. Intervention: The patient underwent a retrosigmoid approach, and the calcified mass, tightly adherent to the lower CNs, was gently removed. The histopathological examination was consistent with a cavernoma. The postoperative course was characterized by a further lowering in the patient's tone of voice. At the 3-month follow-up examination, the patient showed significant improvement. Conclusion: CPA cavernomas are an extremely rare entity. Symptoms are generally related to CN compression, and subarachnoid hemorrhage is a very rare occurrence. The clinical and radiological appearance may mimic that of other CPA tumors (meningiomas, schwannomas). In spite of the benign nature and the very low risk of hemorrhage, we believe, with support from the literature, that surgical treatment is mandatory to prevent significant neurological deficits owing to the chronic CN compression.

scholarly journals Surgical treatment of dumbbell-shaped jugular foramen schwannomas

2004 ◽  
Vol 17 (2) ◽  
pp. 56-62 ◽  
Author(s):  
Paulo A. S. Kadri ◽  
Ossama Al-Mefty
Keyword(s):  
Cranial Nerve ◽  
Recovery Of Function ◽  
Preoperative Evaluation ◽  
Cranial Nerves ◽  
Jugular Foramen ◽  
Jugular Bulb ◽  
Senior Author ◽  
Neurological Deficits ◽  
Cystic Degeneration ◽  
Lower Cranial Nerves

Object Schwannomas of the jugular foramen are rare, comprising between 2 and 4% of intracranial schwannomas. The authors retrospectively analyzed their surgical experience with schwannomas of the lower cranial nerves that presented with intra- and extracranial extensions through an enlarged jugular foramen. The transcondylar suprajugular approach was used without sacrificing the labyrinth or the integrity of the jugular bulb. In this report the clinical and radiological features are discussed and complications are analyzed. Methods This retrospective study includes six patients (three women and three men, mean age 31.6 years) with dumbbell-shaped jugular foramen schwannomas that were surgically treated by the senior author during a 5.5-year period. One patient had undergone previous surgery elsewhere. Glossopharyngeal and vagal nerve deficits were the most common signs (appearing in all patients), followed by hypoglossal and accessory nerve deficits (66.6%). Two or more signs or symptoms were present in every patient. Three tumors presented with cystic degeneration. In four patients the jugular bulb was not patent on neuroimaging studies. The suprajugular approach was used in five patients; the origin of the tumor from the 10th cranial nerve could be defined in three of them. All lesions were completely resected. No death or additional postoperative cranial nerve deficits occurred in this series. Aspiration pneumonia developed in one patient. Preoperative deficits of the ninth and 10th cranial nerves improved in one third of the patients and half recovered mobility of the tongue. No recurrence was discovered during the mean follow-up period of 32.8 months. Conclusions With careful, extensive preoperative evaluation and appropriate planning of the surgical approach, dumbbell-shaped jugular foramen schwannomas can be radically and safely resected without creating additional neurological deficits. Furthermore, recovery of function in the affected cranial nerves can be expected.

Somatosensory Evoked Potential Monitoring During Endoscopic Endonasal Approach to Skull Base Surgery: Analysis of Observed Changes

2011 ◽  
Vol 69 (suppl_1) ◽  
pp. ons64-ons76 ◽  
Author(s):  
Parthasarathy D Thirumala ◽  
Amin B. Kassasm ◽  
Miguel Habeych ◽  
Kelley Wichman ◽  
Yue-Fang Chang ◽  
...  
Keyword(s):  
Evoked Potentials ◽  
Skull Base ◽  
Skull Base Surgery ◽  
Cranial Nerves ◽  
Neurological Deficits ◽  
Intraoperative Neurophysiological Monitoring ◽  
Neurophysiological Monitoring ◽  
Endonasal Approach ◽  
Invasive Approach ◽  
Neurovascular Structures

Abstract BACKGROUND: Intraoperative neurophysiological monitoring, including upper- and lower-extremity somatosensory evoked potentials (SSEPs), has been used to identify and prevent injury to neurovascular structures during conventional skull base surgery. The expanded endonasal approach (EEA) is a novel minimally invasive approach to skull base surgery. However, it carries the risk of injury to neurovascular structures, including the internal carotid artery, anterior cerebral artery, and cranial nerves. OBJECTIVE: To evaluate the value of SSEP monitoring to predict and/or prevent neurovascular deficits during EEA to skull base surgery. METHODS: We retrospectively identified 999 consecutive patients who had intraoperative neurophysiological monitoring during EEA skull base surgery at our institution. A total of 976 patients had SSEP monitoring and a documented postoperative neurological examination. RESULTS: The incidence of changes in SSEP during the procedure was 20 of 976 (2%). The incidence of new postoperative neurological deficits was 5 of 976 (0.5%). The positive and negative predictive values of SSEPs during EEA to predict neurovascular deficits were 80.00% and 99.79%, respectively. CONCLUSION: Intraoperative SSEP monitoring was able to identify impending risk to neurovascular structures to prevent permanent postoperative neurological deficits. We advocate a comprehensive approach to neurophysiological monitoring during EEAs, including SSEPs, spontaneous and triggered electromyography of the cranial nerves III through XII, brainstem auditory evoked potentials, and electroencephalogram, depending on the surgical approach and location of the neural structures at risk.

Microsurgical resection of foramen magnum meningioma through a transcondylar approach: three-dimensional operative video

2019 ◽  
Vol 1 (2) ◽  
pp. V3
Author(s):  
Guilherme H. W. Ceccato ◽  
Rodolfo F. M. da Rocha ◽  
Duarte N. C. Cândido ◽  
Wladimir O. Melo ◽  
Marcio S. Rassi ◽  
...  
Keyword(s):  
Nerve Palsy ◽  
Three Dimensional ◽  
Foramen Magnum ◽  
Complete Resection ◽  
Neurophysiological Monitoring ◽  
Cervical Instability ◽  
Transcondylar Approach ◽  
Postoperative Mri ◽  
Microsurgical Resection

Foramen magnum (FM) meningiomas are challenging lesions. We present the case of a 38-year-old female with neck pain, dysphonia, and slight twelfth nerve palsy. Imaging workup was highly suggestive of an FM meningioma, and microsurgical resection with the aid of intraoperative neurophysiological monitoring was indicated. A transcondylar approach was employed, the vertebral artery was mobilized, and the tumor was completely removed. Postoperative MRI demonstrated complete resection. There were no signs of cervical instability. The patient presented with improvement of her symptoms and no new neurological deficit on follow-up. FM meningiomas can be successfully resected using a transcondylar approach, since it increases the exposure of the ventral FM, allowing the surgeon to work parallel to the skull base and flush with the tumor’s attachment. Informed consent was obtained from the patient for publication of this operative video.The video can be found here: https://youtu.be/itfUOB-6zM0.

Sign in / Sign up

Export Citation Format

Share Document