Level I to III craniofacial approaches based on Barrow classification for treatment of skull base meningiomas: surgical technique, microsurgical anatomy, and case illustrations

2011 ◽  
Vol 30 (5) ◽  
pp. E5 ◽  
Author(s):  
Emel Avcı ◽  
Erinç Aktüre ◽  
Hakan Seçkin ◽  
Kutluay Uluç ◽  
Andrew M. Bauer ◽  
...  
Keyword(s):  
Surgical Technique ◽  
Skull Base ◽  
Surgical Anatomy ◽  
Microsurgical Anatomy ◽  
Middle Point ◽  
The Mean ◽  
The Right ◽  
Skull Base Meningiomas ◽  
Supraorbital Foramen ◽  
Ethmoidal Foramen

Object Although craniofacial approaches to the midline skull base have been defined and surgical results have been published, clear descriptions of these complex approaches in a step-wise manner are lacking. The objective of this study is to demonstrate the surgical technique of craniofacial approaches based on Barrow classification (Levels I–III) and to study the microsurgical anatomy pertinent to these complex craniofacial approaches. Methods Ten adult cadaveric heads perfused with colored silicone and 24 dry human skulls were used to study the microsurgical anatomy and to demonstrate craniofacial approaches in a step-wise manner. In addition to cadaveric studies, case illustrations of anterior skull base meningiomas were presented to demonstrate the clinical application of the first 3 (Levels I–III) approaches. Results Cadaveric head dissection was performed in 10 heads using craniofacial approaches. Ethmoid and sphenoid sinuses, cribriform plate, orbit, planum sphenoidale, clivus, sellar, and parasellar regions were shown at Levels I, II, and III. In 24 human dry skulls (48 sides), a supraorbital notch (85.4%) was observed more frequently than the supraorbital foramen (14.6%). The mean distance between the supraorbital foramen notch to the midline was 21.9 mm on the right side and 21.8 mm on the left. By accepting the middle point of the nasofrontal suture as a landmark, the mean distances to the anterior ethmoidal foramen from the middle point of this suture were 32 mm on the right side and 34 mm on the left. The mean distance between the anterior and posterior ethmoidal foramina was 12.3 mm on both sides; the mean distance between the posterior ethmoidal foramen and distal opening of the optic canal was 7.1 mm on the right side and 7.3 mm on the left. Conclusions Barrow classification is a simple and stepwise system to better understand the surgical anatomy and refine the techniques in performing these complex craniofacial approaches. On the other hand, thorough anatomical knowledge of the midline skull base and variations of the neurovascular structures is crucial to perform successful craniofacial approaches.

Usefulness of Imaging Fusion for Therapeutic Planning in Skull Base Lesions

2003 ◽  
Vol 16 (2) ◽  
pp. 299-305
Author(s):  
E. Puglielli ◽  
R. Galzio ◽  
A. Ricci ◽  
A. Splendiani ◽  
F. Iannessi ◽  
...  
Keyword(s):  
Skull Base ◽  
Posterior Fossa ◽  
Foramen Magnum ◽  
Mean Value ◽  
Trigeminal Schwannoma ◽  
Correct Definition ◽  
Skull Base Lesions ◽  
The Mean ◽  
Planum Sphenoidale ◽  
Skull Base Meningiomas

We propose critical considerations on the usefulness of CT, MRI, and fMRI imaging fusion for the treatment of skull base lesions evaluating 41 cases (24 meningiomas: six petroclival, seven clinoidal, four olfactory, two in the foramen magnum, two spheno-petro-clival, one in the planum sphenoidale, one in the posterior pyramid and one in the PCA; five acoustic schwannomas, three epidermoids, two pituitary adenomas, two craniopharingiomas, two posterior fossa aneurysms, one trigeminal schwannoma, one dermoid and one juvenile angiofibroma). Data were collected, fused, integrated and reconstructed by a dedicated Stealth-Station system for Neuronavigation. CT images were acquired on axial non-overlapping slices, 1–3 mm thick; MRI images were obtained with a 1.5 T system, same FOV and thickness. During surgery the Mean Fiducially Error measured at 6 cm depth and anatomical distortion due to CSF loss was evaluated. Neuronavigation was possible in all cases and successfully applied in preoperative planning and during surgical procedures. The Mean Fiducially Error at 6 cm was 1.7 mm. CSF loss during surgery produced modifications on planned anatomy in a mean value of 0.6 mm. In all cases, imaging fusion for pre and intra-operative neuronavigation provided great advantages in the choice of the best approach, placing of bone flap, correct definition of tumour boundaries and meningeal implant, relationship with functional areas, early identification and real-time correction of the surgical route with respect of deep normal or distorted anatomic or pathologic structures and their eventual encasement or involvement by the pathologic primary process. Neuronavigation appeared ideal for skull base meningiomas making surgical manoeuvres safer, more effective and less invasive. In skull base lesions, CSF loss appeared not significant due to the fact that posterior fossa structures are strictly connected to each other and to the bone, thus are poorly affected by surgical deliquoration. We propose the possible extension of imaging fusion technique with the aim of optimizing the target in radiotherapy for intracranial tumours.

Radiosurgery for large-volume (> 10 cm3) benign meningiomas

2010 ◽  
Vol 112 (5) ◽  
pp. 951-956 ◽  
Author(s):  
Jonathan M. Bledsoe ◽  
Michael J. Link ◽  
Scott L. Stafford ◽  
Paul J. Park ◽  
Bruce E. Pollock
Keyword(s):  
Skull Base ◽  
Large Volume ◽  
Tumor Control ◽  
Skull Base Tumors ◽  
Who Grade ◽  
Average Tumor Volume ◽  
The Mean ◽  
Skull Base Meningiomas ◽  
Supratentorial Tumors

Object Stereotactic radiosurgery (SRS) has proven to be a safe and effective treatment for many patients with intracranial meningiomas. Nevertheless, the morbidity associated with radiosurgery of larger meningiomas is poorly understood. Methods The authors performed a retrospective review of 116 patients who underwent SRS for meningiomas (WHO Grade I) > 10 cm3 between 1990 and 2007, with a minimum follow-up of 12 months. Patients with atypical or malignant meningiomas and those who received prior radiotherapy were excluded. The average tumor volume was 17.5 cm3 (range 10.1–48.6 cm3); the average tumor margin dose was 15.1 Gy (range 12–18 Gy); and the mean follow-up duration was 70.1 months (range 12–199 months). Results Tumor control was 99% at 3 years and 92% at 7 years after radiosurgery. Thirty complications after radiosurgery were noted in 27 patients (23%), including 7 cases of seizures, 6 cases of hemiparesis, 5 cases of trigeminal injury, 4 cases of headaches, 3 cases of diplopia, 2 cases each of cerebral infarction and ataxia, and 1 case of hearing loss. Patients with supratentorial tumors experienced a higher complication rate compared with patients with skull base tumors (44% compared with 18%) (hazard ratio 2.9, 95% CI 1.3–6.7, p = 0.01). Conclusions The morbidity associated with SRS for patients with benign meningiomas > 10 cm3 is greater for supratentorial tumors compared with skull base tumors. Whereas radiosurgery is relatively safe for patients with large-volume skull base meningiomas, resection should remain the primary disease management for the majority of patients with large-volume supratentorial meningiomas.

scholarly journals Anterior skull base meningiomas: surgery related hypothalamic sequalae. How to avoid?

2018 ◽  
Vol 32 (1) ◽  
pp. 94-104
Author(s):  
Ashraf El Badry ◽  
Ahmed Nageeb Taha
Keyword(s):  
Surgical Technique ◽  
Skull Base ◽  
Cranial Nerves ◽  
Conformal Radiotherapy ◽  
Vascular Supply ◽  
Anterior Skull Base ◽  
Initial Surgery ◽  
Before And After ◽  
Hypothalamic Function ◽  
Skull Base Meningiomas

Abstract Introduction: Surgical: morbidities related to anterior skull base meningiomas are widely addressed in the literature and mostly related to tumor relations to cranial nerves and vascular structures in this challenging area. However; there is infrequent complications related to hypothalamic insult either from direct affection or via manipulation of vascular supply of this area. The aim of this study: is to address hypothalamic complications occurred after surgery for anterior skull base meningiomas, pitfalls in our surgical technique and the way to minimize such morbidities. Patients and methods: Retrospective study was conducted on all patients who did surgery for anterior skull base meningiomas in the neurosurgery department, Mansoura University during the period from 2011 to 2016. All the patients clinical and radiological data before and after surgery were analyzed. All patients who developed transient or permeant hypothalamic manifestation were included in this study and data regarding their tumor morphology, surgical technique and post-operative early and late imaging were assessed. Results: Among 93 patients who did surgery for anterior skull base meningiomas; 12 patients developed post-operative sequalae related to hypothalamic function. In 7 patients; tumor was recurrent and in 4 patients; conformal radiotherapy was given after the initial surgery. Complication was transient in 3 patients and permeant in 9 patients. 8 patients died from their hypothalamic sequalae. Early post-operative imaging showed hypothalamic infarction in 8 patients. Conclusion: Through reviewing these cases we can address the importance of many factors in the tumours especially size, morphology, recurrence who increase hypothalamic insults. Factors in surgery include preservation of arachnoid plain, perforators, meticulous dissection for minimize this complication.

scholarly journals Fractionated Gamma Knife radiosurgery for skull base meningiomas: a single-institution experience

2019 ◽  
Vol 46 (6) ◽  
pp. E8 ◽  
Author(s):  
Krishna C. Joshi ◽  
Alankrita Raghavan ◽  
Baha’eddin Muhsen ◽  
Jason Hsieh ◽  
Hamid Borghei-Razavi ◽  
...  
Keyword(s):  
Skull Base ◽  
Gamma Knife ◽  
Tumor Volume ◽  
Gamma Knife Radiosurgery ◽  
Cranial Neuropathy ◽  
High Dose ◽  
Perilesional Edema ◽  
The Mean ◽  
Skull Base Meningiomas

OBJECTIVEGamma Knife radiosurgery (GKRS) has been successfully used for the treatment of intracranial meningiomas given its steep dose gradients and high-dose conformality. However, treatment of skull base meningiomas (SBMs) may pose significant risk to adjacent radiation-sensitive structures such as the cranial nerves. Fractionated GKRS (fGKRS) may decrease this risk, but until recently it has not been practical with traditional pin-based systems. This study reports the authors’ experience in treating SBMs with fGKRS, using a relocatable, noninvasive immobilization system.METHODSThe authors performed a retrospective review of all patients who underwent fGKRS for SBMs between 2013 and 2018 delivered using the Extend relocatable frame system or the Icon system. Patient demographics, pre- and post-GKRS tumor characteristics, perilesional edema, prior treatment details, and clinical symptoms were evaluated. Volumetric analysis of pre-GKRS, post-GKRS, and subsequent follow-up visits was performed.RESULTSTwenty-five patients met inclusion criteria. Nineteen patients were treated with the Icon system, and 6 patients were treated with the Extend system. The mean pre-fGKRS tumor volume was 7.62 cm3 (range 4.57–13.07 cm3). The median margin dose was 25 Gy delivered in 4 (8%) or 5 (92%) fractions. The median follow-up time was 12.4 months (range 4.7–17.4 months). Two patients (9%) experienced new-onset cranial neuropathy at the first follow-up. The mean postoperative tumor volume reduction was 15.9% with 6 patients (27%) experiencing improvement of cranial neuropathy at the first follow-up. Median first follow-up scans were obtained at 3.4 months (range 2.8–4.3 months). Three patients (12%) developed asymptomatic, mild perilesional edema by the first follow-up, which remained stable subsequently.CONCLUSIONSfGKRS with relocatable, noninvasive immobilization systems is well tolerated in patients with SBMs and demonstrated satisfactory tumor control as well as limited radiation toxicity. Future prospective studies with long-term follow-up and comparison to single-session GKRS or fractionated stereotactic radiotherapy are necessary to validate these findings and determine the efficacy of this approach in the management of SBMs.

Vascular geometry of the extracranial carotid arteries: an analysis of length, diameter, and tortuosity

2015 ◽  
Vol 8 (5) ◽  
pp. 536-540 ◽  
Author(s):  
Farooq A Choudhry ◽  
John T Grantham ◽  
Ansaar T Rai ◽  
Jeffery P Hogg
Keyword(s):  
Carotid Artery ◽  
Skull Base ◽  
Aortic Arch ◽  
Carotid Arteries ◽  
Internal Carotid ◽  
Men And Women ◽  
Significant Difference ◽  
The Common ◽  
The Mean ◽  
The Right

BackgroundStable access is essential for successful intracranial interventions. Quantifying variations in extracranial carotid arteries may help in the selection and development of access catheters. This study describes the vascular dimensions from the aortic arch to the skull base.MethodsCT angiography analysis was performed on 100 patients. The lengths, diameters, and tortuosity of the common carotid artery (CCA) and internal carotid artery (ICA) were measured from the aortic arch to the skull base.ResultsThe mean±SD length of the carotid artery from the aortic arch to the skull base was 22.2±2.2 cm for the right side and 20.8±1.9 cm for the left side (p<0.0001). The length of the right CCA was 13.6±1.2 cm and the length of the left CCA was 12.4±1.4 cm (p<0.0001). The length of the right ICA was 8.6±1.4 cm compared with 8.4±1.4 cm for the left ICA (p=0.3). The ICA length in men and women was 8.9±1.3 cm and 8.2±1.3 cm, respectively (p=0.0001), and the CCA length in men and women was 13.6±1.5 cm and 12.3±1.6 cm, respectively (p<0.0001). The lengths of the CCA and ICA in patients aged ≥60 years were 13.3±1.7 cm and 8.9±1.5 cm, respectively compared with 12.8±1.7 cm and 8.2±1.1 cm, respectively, for patients aged <60 years (p=0.04 for CCA, p=0.0002 for ICA). Tortuosity of the CCA and ICA was 1.2±0.2 and 1.3±0.1, respectively, in patients aged ≥60 years compared with 1.1±0.1 for both the ICA and CCA in patients aged <60 years (p<0.0001 for both). There was a consistent ratio of CCA/ICA length of 1.6±0.3 on the right and 1.5±0.3 on the left (p<0.0001). The arterial diameters did not show any significant difference.ConclusionsThe distance from the aortic arch to the skull base is longer on the right than on the left side. Both the CCA and ICA are longer in men and in patients aged ≥60 years. The tortuosity of both segments significantly increases with age.

scholarly journals Microsurgical anatomy of the arterial basket of the conus medullaris

2015 ◽  
Vol 22 (6) ◽  
pp. 672-676 ◽  
Author(s):  
Nikolay L. Martirosyan ◽  
M. Yashar S. Kalani ◽  
G. Michael Lemole ◽  
Robert F. Spetzler ◽  
Mark C. Preul ◽  
...  
Keyword(s):  
Blood Supply ◽  
Vascular Malformations ◽  
Conus Medullaris ◽  
Microsurgical Anatomy ◽  
Arteriovenous Fistulas ◽  
Mean Diameter ◽  
The Mean ◽  
Posterior Spinal Arteries ◽  
The Right ◽  
Formalin Fixed

OBJECT The arterial basket of the conus medullaris (ABCM) consists of 1 or 2 arteries arising from the anterior spinal artery (ASA) and circumferentially connecting the ASA and the posterior spinal arteries (PSAs). The arterial basket can be involved in arteriovenous fistulas and arteriovenous malformations of the conus. In this article, the authors describe the microsurgical anatomy of the ABCM with emphasis on its morphometric parameters and important role in the intrinsic blood supply of the conus medullaris. METHODS The authors performed microsurgical dissections on 16 formalin-fixed human spinal cords harvested within 24 hours of death. The course, diameter, and branching angles of the arteries comprising the ABCM were then identified and measured. In addition, histological sections were obtained to identify perforating vessels arising from the ABCM. RESULTS The ASA tapers as it nears the conus medullaris (mean preconus diameter 0.7 ± 0.12 mm vs mean conus diameter 0.38 ± 0.08 mm). The ASA forms an anastomotic basket with the posterior spinal artery (PSA) via anastomotic branches. In most of the specimens (n= 13, 81.3%), bilateral arteries formed connections between the ASA and PSA. However, in the remaining specimens (n= 3, 18.7%), a unilateral right-sided anastomotic artery was identified. The mean diameter of the right ABCM branch was 0.49 ± 0.13 mm, and the mean diameter of the left branch was 0.53 ± 0.14 mm. The mean branching angles of the arteries forming the anastomotic basket were 95.9° ± 36.6° and 90° ± 34.3° for the right- and left-sided arteries, respectively. In cases of bilateral arterial anastomoses between the ASA and PSA, the mean distance between the origins of the arteries was 4.5 ± 3.3 mm. Histological analysis revealed numerous perforating vessels supplying tissue of the conus medullaris. CONCLUSIONS The ABCM is a critical anastomotic connection between the ASA and PSA, which play an important role in the intrinsic blood supply of the conus medullaris. The ABCM provides an important compensatory function in the blood supply of the spinal cord. Its involvement in conus medullaris vascular malformations makes it a critical anatomical structure.

scholarly journals Decision-making algorithm for minimally invasive approaches to anterior skull base meningiomas

2018 ◽  
Vol 44 (4) ◽  
pp. E7 ◽  
Author(s):  
Malte Ottenhausen ◽  
Kavelin Rumalla ◽  
Andrew F. Alalade ◽  
Prakash Nair ◽  
Emanuele La Corte ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Skull Base ◽  
Anterior Skull Base ◽  
Cribriform Plate ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Olfactory Groove ◽  
Incision Size ◽  
The Mean ◽  
Skull Base Meningiomas

OBJECTIVEAnterior skull base meningiomas are benign lesions that cause neurological symptoms through mass effect on adjacent neurovascular structures. While traditional transcranial approaches have proven to be effective at removing these tumors, minimally invasive approaches that involve using an endoscope offer the possibility of reducing brain and nerve retraction, minimizing incision size, and speeding patient recovery; however, appropriate case selection and results in large series are lacking.METHODSThe authors developed an algorithm for selecting a supraorbital keyhole minicraniotomy (SKM) for olfactory groove meningiomas or an expanded endoscopic endonasal approach (EEA) for tuberculum sella (TS) or planum sphenoidale (PS) meningiomas based on the presence or absence of olfaction and the anatomical extent of the tumor. Where neither approach is appropriate, a standard transcranial approach is utilized. The authors describe rates of gross-total resection (GTR), olfactory outcomes, and visual outcomes, as well as complications, for 7 subgroups of patients. Exceptions to the algorithm are also discussed.RESULTSThe series of 57 patients harbored 57 anterior skull base meningiomas; the mean tumor volume was 14.7 ± 15.4 cm3 (range 2.2–66.1 cm3), and the mean follow-up duration was 42.2 ± 37.1 months (range 2–144 months). Of 19 patients with olfactory groove meningiomas, 10 had preserved olfaction and underwent SKM, and preservation of olfaction in was seen in 60%. Of 9 patients who presented without olfaction, 8 had cribriform plate invasion and underwent combined SKM and EEA (n = 3), bifrontal craniotomy (n = 3), or EEA (n = 2), and one patient without both olfaction and cribriform plate invasion underwent SKM. GTR was achieved in 94.7%. Of 38 TS/PS meningiomas, 36 of the lesions were treated according to the algorithm. Of these 36 meningiomas, 30 were treated by EEA and 6 by craniotomy. GTR was achieved in 97.2%, with no visual deterioration and one CSF leak that resolved by placement of a lumbar drain. Two patients with tumors that, based on the algorithm, were not amenable to an EEA underwent EEA nonetheless: one had GTR and the other had a residual tumor that was followed and removed via craniotomy 9 years later.CONCLUSIONSUtilizing a simple algorithm aimed at preserving olfaction and vision and based on maximizing use of minimally invasive approaches and selective use of transcranial approaches, the authors found that excellent outcomes can be achieved for anterior skull base meningiomas.

scholarly journals ORBITAL MORPHOLOGY WITH REFERENCE TO BONY LANDMARKS. 20 La morfología de la órbita en relación a los parámetros óseos

2016 ◽  
Vol 6 (1) ◽  
pp. 20-25
Author(s):  
Shilpa N Gosavi ◽  
Surekha D Jadhav ◽  
Balbhim R Zambare
Keyword(s):  
Racial Differences ◽  
Lateral Wall ◽  
Inferior Margin ◽  
Bony Landmarks ◽  
Orbital Wall ◽  
Measured Distance ◽  
The Mean ◽  
Supraorbital Foramen ◽  
Anterior Lacrimal Crest ◽  
Ethmoidal Foramen

Las órbitas óseas son cavidades del esqueleto situadas a cada lado de la nariz. Se conocen las diferencias raciales en las medidas orbitales. El objetivo del presente estudio era determinar las distancias de varias fisuras y foramen en la órbita en relación a ciertos puntos de referencia óseos / quirúrgicos sobre los márgenes orbitales en la población india, lo que puede ser útil durante la cirugía orbital. La distancia de canal óptico (OC), fisura orbitaria superior (SOF), fisura orbital inferior (IOF) y forámenes lagrimales (LF) se mide a partir de puntos de referencia como cresta lacrimal anterior (ALC) para la pared medial, muesca/foramen supra orbital (SN) para la pared superior, sutura  cigomática frontal (FZ) de la pared lateral y un punto en el margen inferior (OIM) justo encima del agujero infraorbitario. Se midió  la distancia del foramen etmoidal anterior y posterior (AEF y PEF) de ALC. Se observó la presencia de foramen etmoidal media (MEF) y forámenes lagrimales (LF).La distancia media de OC fue 39,71 ±2,67 mm(deALC), 45,11 ±3,4 mm(de SN) , 48,32 ±2,8 mm(de FZ ) y 45,97 ±3,9 mm(de  OIM). La distancia segura para el nervio óptico para cada pared orbital se calcula restando5 mmde la distancia más corta medida. The bony orbits are skeletal cavities located on either side of the nose. Racial differences in orbital measurements are known. The aim of the present study was to determine the distances of various fissures and foramen in the orbit with reference to certain bony / surgical landmarks on the orbital margins in Indian population which can be useful during various surgical procedures. The distance of optic canal (OC), superior orbital fissure (SOF), inferior orbital fissure (IOF), lacrimal foramen (LF) were measured from landmarks like anterior lacrimal crest (ALC) for medial wall, supraorbital foramen/ notch (SON) for superior wall, fronto-zygomatic suture (FZ) for lateral wall and a point on inferior margin (IOM) just above the infraorbital foramen. Distance of anterior and posterior ethmoidal foramen (AEF and PEF) from ALC was measured. The incidence of middle ethmoidal foramen (MEF) and lacrimal foramen (LF) was noted. The mean distance of OC was 39.71 ±2.67 mm(from ALC), 45.11 ±3.4 mm(from SN), 45.97 ±3.9 mm(from FZ) and 48.32 ±2.8 mm(from IOM). The safe distance for optic nerve for each orbital wall was derived by subtracting5 mmfrom the shortest measured distance.

Microsurgical Anatomy of Subtotal Temporal Bone Resection En Bloc With the Parotid Gland and Temporomandibular Joint

2014 ◽  
Vol 10 (2) ◽  
pp. 334-356 ◽  
Author(s):  
Noritaka Komune ◽  
Shizuo Komune ◽  
Takashi Morishita ◽  
Albert L. Rhoton
Keyword(s):  
Surgical Technique ◽  
Parotid Gland ◽  
Temporomandibular Joint ◽  
Temporal Bone ◽  
Infratemporal Fossa ◽  
Surgical Anatomy ◽  
Microsurgical Anatomy ◽  
Bone Resection ◽  
En Bloc ◽  
Temporal Bone Resection

AbstractBACKGROUND:Subtotal temporal bone resection (STBR) has been used for half a century to remove temporal bone malignancies. However, there are few reports on the detailed anatomy involved in the resection.OBJECTIVE:To describe the microsurgical anatomy of STBR combined en bloc with the resection of the parotid gland and temporomandibular joint (TMJ).METHODS:Cadaveric specimens were dissected in a stepwise manner using 3× to 40× magnification.RESULTS:STBR can be combined with the total parotidectomy and the resection of the TMJ if the tumor extends into the parotid gland, TMJ, or facial nerve. In this study, we describe the step-by-step microsurgical anatomy of STBR en bloc with the parotid gland and TMJ. The surgical technique described combines 3 approaches: the high cervical, subtemporal-infratemporal fossa, and retromastoid-paracondylar approaches. Combining these 3 approaches aided in efficiently completing this modified approach.CONCLUSION:STBR is a complicated and technically challenging procedure. This study highlights the importance of understanding the surgical anatomy of STBR and will serve as a catalyst for improvement of the surgical technique for temporal bone resection.

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