Presigmoid Transpetrosal Approach Research Articles

Abordaje presigmoideo transpetroso (petrosectomía parcial) combinado con abordaje subtemporal transtentorial para meningioma petroclival

Introduction: Petroclival meningiomas constitute 3 to 10% of meningiomas of the posterior fossa, they originate in the petroclival fissure, in the upper part of the clivus, petrosal apex, and medial to the trigeminal nerve. Resection of these tumors is a neurosurgical challenge. The combined partial petrosectomy approach associated with a sub-temporal approach is a technique described by various authors; however, its performance is considered highly complex. We report the case of a petroclival meningioma operated successfully in our hospital using a combined presigmoid and subtemporal transtentorial transpetrosal approach. Clinical case: 33-year-old female patient with a clinical picture of headache, nausea, and gait disturbance. Brain magnetic resonance imaging showed a large right petroclival tumor (4.2x3.9x3.8cm) that displaced the brainstem and secondary hydrocephalus. The hydrocephalus was treated with a ventricular peritoneal shunt. Then, the tumor was resected using a combined presigmoid and subtemporal transpetrosal approach, a technique that allowed adequate exposure of the tumor, achieving complete resection, without intraoperative complications. Postoperative evolution was favorable, with no sequelae. Conclusion: The combined presigmoid and transtentorial subtemporal transpetrous approach for petroclival meningiomas is an effective and feasible technique to perform in our environment. The support of technology such as Neuronavigation, the ultrasonic aspirator, intraoperative monitoring, and adequate experience in skull base surgery are fundamental factors for the success of this surgery. Keywords: Meningioma, Skull Base Neoplasms, Craniotomy, Neurosurgical Procedures. (Source: MeSH NLM)

Presigmoid Transpetrosal Approach for Superficial Temporal Artery to Distal Posterior Cerebral Artery Bypass and Trapping of Aneurysm.

BACKGROUND AND IMPORTANCEAneurysms of the posterior cerebral artery (PCA) are uncommon, estimated at less than 1% of all cerebral aneurysms, and less than half occur distal to the P1/2 junction. Unfortunately, the conventional bypass approach for PCA aneurysms—primarily occipital artery to distal PCA cortical branches—has a history of unsatisfying results.CLINICAL PRESENTATIONA 42-yr-old female presented with Fisher 3 Hunt-Hess 2 subarachnoid hemorrhage secondary to ruptured distal PCA aneurysm. She was initially evaluated by the endovascular service, but due to recent subarachnoid hemorrhage, endovascular treatment with flow diversion and/or vessel sacrifice was felt to be relatively contraindicated and the patient was referred for surgical evaluation for possible bypass. The patient subsequently underwent surgery for trapping of aneurysm and concomitant superficial artery to distal PCA bypass.CONCLUSIONA novel approach for the treatment of a ruptured distal PCA aneurysm is described, consisting of posterior transpetrosal exposure and division of the tentorium with superficial temporal artery to P3 bypass.

Commentary: Presigmoid Transpetrosal Approach for Superficial Temporal Artery to Distal Posterior Cerebral Artery Bypass and Trapping of Aneurysm.

Commentary: Presigmoid Transpetrosal Approach for Superficial Temporal Artery to Distal Posterior Cerebral Artery Bypass and Trapping of Aneurysm.

Localization of Anterosuperior Point of Transverse-sigmoid Sinus Junction Using a Reference Coordinate System on Lateral Skull Surface.

Background:During craniotomies using the transpetrosal-presigmoid approach, exposure of the sigmoid sinus remains an essential but hazardous step. In such procedures, accurate localization of the anterosuperior point of the transverse-sigmoid sinus junction (ASTS) is very important for reducing surgical morbidity. This study aimed to create an accurate and practical method for identifying the ASTS.Methods:On the lateral surfaces of 40 adult skulls (19 male skulls and 21 female skulls), a rectangular coordinate system was defined to measure the x and y coordinates of two points: the ASTS and the squamosal-parietomastoid suture junction (SP). With the coordinate system, the distribution characteristics of the ASTS were statistically analyzed and the differences between the ASTS and SP were investigated.Results:For ASTS-x, significant differences were found in different sides (P = 0.020); the ASTS-x in male skulls was significantly higher on the right side (P = 0.017); there was no significant difference between the sides in female skulls. There were no significant differences in gender or interaction of gender and side for ASTS-x, and for ASTS-y, there were no significant differences in side, gender, or interaction of gender and side. For both sides combined, the mean ASTS-x was significantly higher than the mean SP-x (P = 0.003) and the mean ASTS-y was significantly higher than the mean SP-y (P = 0.011).Conclusions:This reference coordinate system may be an accurate and practical method for identifying the ASTS during presigmoid craniotomy. The SP might be difficult to find during presigmoid craniotomy and, therefore, it is not always a reliable landmark for defining the ASTS.

Partial labyrinthectomy presigmoid transpetrosal resection of petroclival meningioma

A petroclival meningioma represents a challenging tumor to resect in the cerebellopontine angle and ventral to the brain stem. Multiple cranial nerves and blood vessels may be intimately involved with the tumor. A partial labyrinthectomy presigmoid transpetrosal approach can facilitate resection while preserving hearing. This approach allows for a direct line of sight along the petrous bone while sealing the canals can preserve hearing. In this video operative manuscript, we demonstrate a step-by-step illustration of a partial labyrinthectomy presigmoid transpetrosal resection of a petroclival meningioma. This approach affords the best chance of hearing preservation and an opportunity for maximum tumor resection. The video can be found here: http://youtu.be/29I4KEXz1vY .

Classification of petroclival meningiomas and selection of surgical approach

Objective To analyze the classification of petroclival meningiomas according to the tumor extension on magnetic resonance imaging ( MRI ) and choice of surgical approach.Methods The clinical data of 318 cases of petroclival meningiomas were retrospectively analyzed.The cases were classified into eight types:petrous apex,cavernous sinus,sphenopetrosal,petroclival,petroclival - cavernous sinus,cerebellopontine angle (CPA),clival and extensive types.The pre- and post -operative statuses were evaluated by Karnofsky Performance Scale (KPS).Results 248 patients were included in the study with a mean preoperative KPS of 73.7 ± 10.3. The most frequent approaches were presigmoid transpetrosal approach (49.6％) followed with subtemporal transpetrosal and transtentorial approach/ Kawase' s approach (STTA/KA) (35.1％ ).Complete resection (Simpson Grade Ⅰ or Ⅱ ) was achieved in 52.4％ patients.The most frequent approach of the first three types was STTA/KA ( 53.7％ ) and presigmoid transpetrosal approach (63.8％) in the latter five types,and the different proportion of approaches used between the two groups was significant (x2 =27.461,P ＜ 0.001 ).The complication rate of cranial nerves Ⅵ,Ⅶ and Ⅷ of presigmoid transpetrosal approach was higher than that of STTA/KA.The recent KPS was 75.8 ±26.9 without statistical difference from preoperative KPS (t =- 1.321,P =0.188 ).Compared with preoperative status,57.7％ patients were improved and 19.0％ were stabilized at recent evaluation.Conclusions Classification of petroclival meningiomas will contribute to the approach selection.STTA/KA approach is fit for the first three types,meanwhile,presigmoid transpetrosal approach is suitable for the latter five types. Comprehensive preoperative evaluation is essential to achieve individualized treatment and favorable prognosis. Key words: Meningioma; Petroclival; Presigmoid approach; Subtemporal approach; Classification

Surgical Simulation of Cerebral Revascularization Via Skull Base Approaches in the Posterior Circulation Using Three-Dimensional Skull Model With Artificial Brain and Blood Vessels

Posterior circulation revascularization is a challenging technique because microanastomosis must be performed in deep locations. A reproducible simulation model is proposed for training. The prototype three-dimensional skull model with artificial brain was used. The mesencephalic segment of superior cerebellar artery (SCA) and the caudal loop of the posterior inferior cerebellar artery (PICA) were made from artificial blood vessels and glued on the brain. The skull model was drilled to perform the presigmoid transpetrosal approach and then superficial temporal artery-SCA anastomosis was performed under the operating microscope. The skull model was also drilled to perform the far lateral approach and then occipital artery-PICA anastomosis was performed. The skull model with artificial brain and arteries allows simulation and training in the surgical techniques of posterior circulation revascularization with skull base approaches.

Characterization of an intracranial neurothekeoma: case report

Neurothekeomas are benign tumors of presumed neural sheath origin. They are primarily found in superficial soft tissues, located in the upper portion of the body. Here, we report a case of intracranial neurothekeoma. A 37-year-old female presented at our clinic with sudden-onset left hemifacial pain of varying duration. The physical and neurological examination findings were normal. The magnetic resonance imaging scan showed a mass compressing the pons and extending from the medial section of the left middle fossa to the posterior fossa. The patient was operated on using a left presigmoid transpetrosal approach and the mass was totally removed. Neurothekeomas, also known as nerve sheath myxomas, are rare benign tumors. There have been two previous cases reported with an intracranial location. The information presented here now represents the third such case in the literature.

Two-bone flap craniotomy for the transpetrosal–presigmoid approach to avoid a bony defect in the periauricular area after surgery on petroclival lesions: technical note

The authors describe a two-bone-flap craniotomy technique to avoid the bone defect caused by the transpetrosal-presigmoid approach. Briefly, this technique includes three steps. The first step is to elevate a temporoparietal bone flap located superiorly to the transverse and sigmoid sinuses. The second step is to dissect the transverse and sigmoid sinuses away from the bone by inserting a gelatin sponge. This maneuver provides hemostasis and protects the sinuses from injury. The third step is to cut a second bone flap including part of the temporal bone and the outer table of the mastoid bone with a high-speed drill system. After the operation, the two bone flaps are fixed in place with titanium osteosynthesis fixation material. This approach provides a simple, easy, and safe technique for the transpetrosal-presigmoid approach. The technique has been performed in 83 patients treated for petroclival neoplasms with excellent cosmetic results.

Cavernomas pontinos extraventriculares. Parte II. Acesso pré-sigmoideo transpetroso a cavernoma pontino ventrolateral

Resumo Objetivo: Descrever a via pré-sigmoidea ampliada para acesso a lesões localizadas na região ventrolateral da ponte, exemplificado com a apresentação de um caso de cavernoma pontino nessa localização. Conclusão: Esse acesso, amplamente revisto pela literatura, é útil para remoção cirúrgica de cavernomas pontinos ventrolaterais.

Two-Bone-Flap Craniotomy for the Transpetrosal-Presigmoid Approach to Avoid a Bony Defect in Periauricular Area After Surgery for Petroclivus Lesions: Technical Note

The authors describe a two-bone-flap craniotomy to avoid the bony defect in the transpetrosal-presigmoid approach. Briefly, this technique includes 3 steps. The fist step is to elevate a temporoparietal bone flap that is located superiorly to the transverse sinus (TS) and sigmoid sinus (SS). The second step is to dissect the TS and SS from the bone by inserting a gelatin sponge. This maneuver provides hemostasis and protects the sinuses from injury. The third step is to cut the second bone flap—part of the temporal bone and the outer table of the mastoid bone—with the Midas Rex drill system. After the operation, the 2 bone flaps are fixed in place with CranioFix clamps. It is a simple, easy, and safe craniotomy technique for the transpetrosal-presigmoid approach. The technique has been performed in 83 patients treated for petroclival neoplasms with excellent cosmetic results.

Quantification of the presigmoid transpetrosal keyhole approach to petroclival region

Despite the presigmoid transpetrosal approach has been used by different researchers in various ways, the surgical injury rate remains high. Applying a minimally invasive keyhole idea, we devised a presigmoid transpetrosal keyhole approach (PTKA), classified and quantitatively assessed their approach to the petroclival area on a cadaver model by using a neuronavigation system. The presigmoid transpetrosal keyhole approach was divided into four increasingly morbidity-producing steps: retrolabyrinthine, partial labyrinthectomy with petrous apicectomy, translabyrinthine and transcochlear keyhole approaches. Six latex-injected cadaveric heads (twelve sides) underwent dissection in which a neuronavigation system was used. An area of exposure 10 cm superficial to a central target (working area) was calculated. The area of clival exposure with each subsequent dissection was also calculated. The retrolabyrinthine keyhole approach (RLK) spares hearing and facial function in theory but provides for only a small window of upper clival exposure. The view afforded by partial labyrinthectomy with petrous apicectomy keyhole approach (PLPAK) provides for up to four times this exposure. The translabyrinthine keyhole approach (TLK) and transcochlear keyhole approach (TCK), although producing more morbidity, add little in terms of a larger petroclival window. However, with each step, the surgical freedom for manipulation of instruments increases. The presigmoid transpetrosal keyhole approach to the petroclival area is feasible and useful. The RLK has relatively limited utility. For lesions without bone invasion, the PLPAK provides a much more versatile exposure with an excellent chance of hearing and facial nerve preservation. The TLK provides for greater versatility in treating lesions but clival exposure is not greatly enhanced. The TCK adds little in terms of intradural exposure but should be reserved for cases in which access to the petrous carotid artery is necessary.

Cosmetic reconstruction after mastoidectomy for the transpetrosal-presigmoid approach: technical note.

We describe the technique of cosmetic reconstruction after mastoidectomy in the transpetrosal-presigmoid approach for petroclival lesions. This technique involves raising a single temporo-occipital bone flap and cosmetic mastoidectomy, removing the mastoid bone fragments (by means of a rongeur instead of an air drill) for later reconstruction. Replacement of the bone fragments mixed with fibrin glue enables tamponade against the dura to be achieved without a fat graft. Computed tomographic scans and plain cranial films taken a few years later showed successful reconstruction of the mastoid bone with a good appearance of the retromastoid area in seven patients who underwent this procedure. The only complication was infection in one patient from cerebrospinal fluid leakage from the wound. We have developed a simple and easy technique of cosmetic reconstruction after the transpetrosal-presigmoid approach.

Surgical approaches for vertebro-basilar trunk aneurysms located in the midline.

Fourteen cases of midline vertebro-basilar trunk aneurysms were operated on by four routes of surgical approach: middle fossa anterior transpetrosal approach (ATP), presigmoid transpetrosal approach (PTP), conventional lateral suboccipital approach (LSO) or suboccipital transcondylar approach (STC). There was no mortality, but the morbidity was different depending on the surgical approach. In basilar trunk aneurysms located higher than the internal auditory canal, excellent results were obtainable by ATP, especially in the case of posteriorly projecting aneurysms. For midline vertebral aneurysms located lower than the internal auditory canal, STC resulted in less surgical complications than LSO. Extradural resection of the jugular tubercle was necessary for aneurysms located on the distal vertebral artery at or close to the vertebro-basilar junction. For vertebro-basilar junction aneurysms located at the level of the internal auditory canal, hearing was preserved by STC, but not by ATP or PTP. However, choice of the surgical approach may depend on the direction of the aneurysm and the technical accessibility of the skull base. All these skull base approaches reduced surgical complications of retraction damage to the cranial nerves and the brain stem. This holds true for all aneurysms arising from the midline vertebro-basilar trunk.