scholarly journals Extended Middle Fossa Approach for Trigeminal Schwannoma Resection

2021 ◽  
Author(s):  
Baha'eddin A. Muhsen ◽  
Edinson Najera ◽  
Hamid Borghei-Razavi ◽  
Badih Adada
Keyword(s):  
Cavernous Sinus ◽  
Brain Mri ◽  
Clinical Status ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Petrous Apex ◽  
Benign Tumors ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
Trigeminal Schwannoma

AbstractTrigeminal schwannomas are rare benign tumors, it is second most common intracranial schwannomas after vestibular schwannomas. The management includes not limited to observation, stereotactic radiosurgery/radiotherapy, and/or surgical resection. Tumor size and patient clinical status are the most important factors in management.In this video, we describe the technical nuances of an extended middle fossa approach for large trigeminal schwannoma with cavernous sinus extension resection. A 44-year-old right-handed female with several months' history of progressive right facial paresthesia and pain in the distribution of V3 mainly. On physical examination, she had decreased sensation to light touch over the right V1 to V3 distribution with loss of cornel reflex. The brain MRI showed 3.5 cm bilobed mass extends from the pontine root entry zone to the cavernous sinus. Craniotomy was performed and followed by middle fossa dural peeling, peeling of temporal lobe dura away from the wall of the cavernous sinus, extradurally anterior clinoidectomy, drilling of the petrous apex, coagulation of superior petrosal sinus followed incision of the tentorium up to the tentorial notch with preservation the fourth cranial nerve, and tumor dissected away from V1 and then gradually removed from the superior wall of the cavernous sinus.The technique presented here allows for complete tumor resection, safe navigation through the relative cavernous sinus compartments, and minimizes the possibility of inadvertent injury to the cranial nerves.The postoperative course was uneventful except for right eye incomplete ptosis from the swelling. Her facial pain subsided after the surgery without any extra ocular movement impairment.The link to the video can be found at: https://youtu.be/zxi2XK2R9QU.

scholarly journals Transcavernous Approach for Gross Total Resection of a Dumbbell-Shaped Giant Trigeminal Schwannoma

2021 ◽  
Author(s):  
Sima Sayyahmelli ◽  
Emel Avci ◽  
Burak Ozaydin ◽  
Mustafa K. Başkaya
Keyword(s):  
Skull Base ◽  
Cavernous Sinus ◽  
Tumor Resection ◽  
Mass Effect ◽  
World Health ◽  
Gross Total Resection ◽  
Petrous Apex ◽  
Total Resection ◽  
Who Grade ◽  
Trigeminal Schwannoma

AbstractTrigeminal schwannomas are rare nerve sheet tumors that represent the second most common intracranial site of occurrence after vestibular nerve origins. Microsurgical resection of giant dumbbell-shaped trigeminal schwannomas often requires complex skull base approaches. The extradural transcavernous approach is effective for the resection of these giant tumors involving the cavernous sinus.The patient is a 72-year-old man with headache, dizziness, imbalance, and cognitive decline. Neurological examination revealed left-sided sixth nerve palsy, a diminished corneal reflex, and wasting of temporalis muscle. Magnetic resonance imaging (MRI) showed a giant homogeneously enhancing dumbbell-shaped extra-axial mass centered within the left cavernous sinus, Meckel's cave, and the petrous apex, with extension to the cerebellopontine angle. There was a significant mass effect on the brain stem causing hydrocephalus. Computed tomography (CT) scan showed erosion of the petrous apex resulting in partial anterior autopetrosectomy (Figs. 1 and 2).The decision was made to proceed with tumor resection using a transcavernous approach. Gross total resection was achieved. The surgery and postoperative course were uneventful, and the patient woke up the same as in the preoperative period. MRI confirmed gross total resection of the tumor. The histopathology was a trigeminal schwannoma, World Health Organization (WHO) grade I. The patient continues to do well without any recurrence 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/TMK5363836M

Zygomatic Approach to Cavernous Sinus Chordoma: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Antonio Aversa ◽  
Ossama Al-Mefty
Keyword(s):  
Carotid Artery ◽  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Cranial Nerves ◽  
Radical Resection ◽  
High Rate ◽  
Petrous Apex ◽  
High Dose ◽  
Middle Fossa ◽  
Cavernous Carotid Artery

Abstract Chordoma is not a benign disease. It grows invasively, has a high rate of local recurrence, metastasizes, and seeds in the surgical field.1 Thus, chordoma should be treated aggressively with radical resection that includes the soft tissue mass and the involved surrounding bone that contains islands of chordoma.2–5 High-dose radiation, commonly by proton beam therapy, is administered after gross total resection for long-term control. About half of chordoma cases occupy the cavernous sinus space and resecting this extension is crucial to obtain radical resection. Fortunately, the cavernous sinus proper extension is the easier part to remove and pre-existing cranial nerves deficit has good chance of recovery. As chordomas originate and are always present extradurally (prior to invading the dura), an extradural access to chordomas is the natural way for radical resection without brain manipulation. The zygomatic approach is key to the middle fossa, cavernous sinus, petrous apex, and infratemporal fossa; it minimizes the depth of field and is highly advantageous in chordoma located mainly lateral to the cavernous carotid artery.6–12 This article demonstrates the advantages of this approach, including the mobilization of the zygomatic arch alleviating temporal lobe retraction, the peeling of the middle fossa dura for exposure of the cavernous sinus, the safe dissection of the trigeminal and oculomotor nerves, and total control of the petrous and cavernous carotid artery. Tumor extensions to the sphenoid sinus, sella, petrous apex, and clivus can be removed. The patient is a 30-yr-old who consented for surgery.

Operative management of tumors involving the cavernous sinus

1986 ◽  
Vol 64 (6) ◽  
pp. 879-889 ◽  
Author(s):  
Laligam N. Sekhar ◽  
Aage R. Møller
Keyword(s):  
Cavernous Sinus ◽  
Cranial Nerve ◽  
Preoperative Evaluation ◽  
Operative Procedure ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Petrous Apex ◽  
Content Type ◽  
The Third ◽  
Fine Print

✓ In the past, neurosurgeons have been reluctant to operate on tumors involving the cavernous sinus because of the possibility of bleeding from the venous plexus or injury to the internal carotid artery (ICA) or the third, fourth, or sixth cranial nerves. The authors describe techniques for a more aggressive surgical approach to neoplasms in this area that are either benign or locally confined malignant lesions. During the last 2 years, seven tumors involving the cavernous sinus have been resected: six totally and one subtotally. The preoperative evaluation included axial and coronal computerized tomography, cerebral angiography, and a balloon-occlusion test of the ICA. Intraoperative monitoring of the third, fourth, sixth, and seventh cranial nerves was used to assist in locating the nerves and in avoiding injury to them. The first major step in the operative procedure was to obtain proximal control of the ICA at the petrous apex and distal control in the supraclinoid segment. The cavernous sinus was then opened by a lateral, superior, or inferior approach for tumor resection. Temporary clipping and suture of the ICA was necessary in one patient. None of the patients died or suffered a stroke postoperatively. Permanent trigeminal nerve injury occurred in three patients; in two, this was the result of tumor invasion. One patient suffered temporary paralysis of the third, fourth, and sixth cranial nerves, and in another the sixth cranial nerve was temporarily paralyzed. Preoperative cranial nerve deficits were improved postoperatively in three patients. Radiation therapy was administered postoperatively to four patients. These seven patients have been followed for 6 to 18 months to date and none has shown evidence of recurrence of the intracavernous tumor.

scholarly journals Petrosal Approach With Preservation of the Superior Petrosal Sinus (the Graceful Petrosal) for Resection of Giant Trigeminal Schwannoma: 2-Dimensional Operative Video

2021 ◽  
Vol 20 (5) ◽  
pp. E342-E343
Author(s):  
Kaith K Almefty ◽  
Ossama Al-Mefty
Keyword(s):  
Magnetic Resonance ◽  
Surgical Resection ◽  
Posterior Fossa ◽  
Tumor Resection ◽  
Venous Drainage ◽  
Petrous Apex ◽  
Benign Tumors ◽  
Nerve Function ◽  
Trigeminal Schwannoma ◽  
Superior Petrosal Sinus

Abstract Trigeminal schwannomas are benign tumors amendable to curative surgical resection.1 Excellent outcomes, with preservation and improvement of cranial nerve function, including trigeminal nerve function, have been reported with microsurgical resection through skull base approaches.2 Dumbell shaped tumors, involving the middle and posterior fossa, are more challenging.3 They are resected via a middle cranial fossa approach with the expanded Meckel cave providing access to the posterior fossa. However, tumors with a large caudal extension below the internal auditory meatus typically cannot be adequately accessed with this approach and the posterior petrosal approach is utilized.2 Specific venous anatomy might deter from cutting the tentorium. This article describes the surgical resection of a trigeminal schwannoma with a large posterior fossa component through a petrosal approach without cutting the tentorium.4 The patient is a 34-yr-old man who presented with headaches and gait disturbance. Neurological exam revealed hypoesthesia and hypoalgesia in the left V1 and V2 distributions. Magnetic resonance imaging (MRI) revealed a large dumbbell-shaped schwannoma causing brainstem compression. Magnetic resonance venography (MRV) demonstrated temporal lobe venous drainage into the superior petrosal sinus and tentorium proximal to the transverse sigmoid junction. A single temporal-suboccipital bone flap and a retro-labrynthine mastoidectomy were performed. The petrous apex was drilled and Meckle's cave opened. The presigmoid dura was opened and extended toward the petrous apex region beneath the tentorium. This provided access to and safe resection of the tumor. A gross total tumor resection was achieved. The patient remained stable neurologically and was without tumor recurrence at 3 yr postoperatively. The patient had consented to the procedure. Figures in video at 4:06 from Jafez et al, Preservation of the superior petrosal sinus during the petrosal approach, J Neurosurg. 2011;114(5):1294-1298, with permission from JNSPG.

scholarly journals Cavernous Sinus Chondromas

2018 ◽  
Vol 26 (3) ◽  
pp. 211-217
Author(s):  
Jonathan Polo Valdez ◽  
Ricardo Ramina ◽  
Luis Fernando Moura Da Silva Jr ◽  
Mauricio Coelho Neto
Keyword(s):  
Cavernous Sinus ◽  
Clinical Symptoms ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
The Body ◽  
Neurological Deficits ◽  
Surgical Approaches ◽  
Benign Tumors ◽  
Surgical Removal ◽  
Adequate Knowledge

Background: Chondromas are benign tumors with slow growth pattern that may develop along the body. Intracranial chondromas are rare, 0.1 to 0.3% of all intracranial tumors, usually in parasellar region. Few papers reported cavernous sinus chordomas. Case Description: We reported two cases of cavernous sinus chondromas. Two patients presented diplopia, one facial hypoesthesia and one presented extension to the petroclival region. Surgical approaches were frontotemporal combining presigmoid/middle fossa. Literature was reviewed concerning incidence, clinical symptoms, treatment and outcome. Both cases achieved complete tumor resection without postoperative complication. Preoperative deficits improved. Literature review confirms their rarity, clinical symptoms are related to deficits of cranial nerves passing through the cavernous sinus and cure can be achieved through radical surgical removal. Conclusion: Cavernous sinus chondromas are rare benign lesions with insidious growth. Adequate knowledge of cavernous sinus anatomy, microsurgical experience, intraoperative monitoring of cranial nerves and neuronavigation allows radical tumor removal with no additional neurological deficits.

Endoscopic Endonasal Interdural Middle Fossa Approach to the Maxillary Nerve: Anatomic Considerations and Surgical Relevance

2017 ◽  
Vol 13 (4) ◽  
pp. 522-528 ◽  
Author(s):  
Kumar Abhinav ◽  
David Panczykowski ◽  
Wei-Hsin Wang ◽  
Carl H. Synderman ◽  
Paul A. Gardner ◽  
...  
Keyword(s):  
Average Length ◽  
Tumor Resection ◽  
Human Head ◽  
Proximal Part ◽  
Gasserian Ganglion ◽  
Middle Fossa ◽  
Perineural Spread ◽  
Endoscopic Endonasal ◽  
Middle Fossa Approach ◽  
Maxillary Nerve

Abstract BACKGROUND: The maxillary nerve (V2) can be approached via the open middle fossa approach. OBJECTIVE: To delineate the anatomy of V2 and its specific segments with respect to the endonasal landmarks. We present the endoscopic endonasal interdural middle fossa approach to V2 and its potential application for the treatment of perineural spread in sinonasal/skull base tumors. METHODS: Five human head silicon-injected specimens underwent bilateral endoscopic endonasal transpterygoid approaches. V2 prominence and the maxillary strut were identified in the lateral recess along with paraclival carotid protruberance. The regions superior and inferior to V2 corresponding to the anteromedial and anterolateral triangles of the middle fossa were exposed. RESULTS: V2 can be classified into 3 segments: interdural (from the Gasserian ganglion to the proximal part of the maxillary strut), intracanalicular (corresponding to the anteroposterior length of the maxillary strut), and pterygopalatine (distal to the maxillary strut and the site of its divisions). Endonasally, the average length of the interdural and the intracanalicular segments were approximately 9 and 4.4 mm, respectively. V2, following its division distal to the maxillary strut, was successfully dissected off the middle fossa dura and transected just distal to the Gasserian ganglion. CONCLUSION: Endonasally, the interdural segment can be safely mobilized between the periosteal and meningeal dural layers while ensuring the integrity of the middle fossa dura. This allows transection of infiltrated V2 to facilitate tumor resection without entering the intradural/arachnoidal space. Posteriorly, this is limited by the Gasserian ganglion and superomedially by the dural envelope surrounding the cavernous sinus and the paraclival carotid artery.

scholarly journals Presigmoid Approach to Dumbbell Trigeminal Schwannoma

2018 ◽  
Vol 79 (S 05) ◽  
pp. S391-S392
Author(s):  
Katherine Kunigelis ◽  
Daniel Craig ◽  
Alexander Yang ◽  
Samuel Gubbels ◽  
A. Youssef
Keyword(s):  
Trigeminal Nerve ◽  
Treatment Options ◽  
Extent Of Resection ◽  
Direct Access ◽  
Petrous Apex ◽  
Total Resection ◽  
Middle Fossa Approach ◽  
Nerve Preservation ◽  
Presigmoid Approach ◽  
Trigeminal Schwannoma

This case is a 15-year-old male, presenting with headaches, right face, and arm numbness, and ataxia. MRI (magnetic resonance imaging) revealed a large right sided dumbbell shaped lesion, extending into the middle and posterior fossa with compression of the brainstem consistent with a trigeminal schwannoma. Treatment options here would be a retrosigmoid suprameatal approach or a lateral presigmoid approach. Given the tumor extension into multiple compartments, a presigmoid craniotomy, combining a middle fossa approach with anterior petrosectomy, and retrolabyrinthine approach with posterior petrosectomy were used to maximize the direct access corridor for resection. The petrous apex was already expanded and remodeled by the tumor. Nerve fascicles preservation technique is paramount to the functional preservation of the trigeminal nerve. The extent of resection should be weighed against the anatomical functional integrity of the nerve. Near total resection is considered if that means more nerve preservation. Postoperatively, the patient had a slight (House–Brackman grade II) facial droop, which resolved over days and developed right trigeminal hypesthesia at several weeks. This case is presented to demonstrate a combined petrosectomy technique for resection of lesions extending into both the middle and posterior cranial fossa with near total resection and trigeminal nerve preservation.The link to the video can be found at: https://youtu.be/kA9GyFhL1dg.

Microsurgical Resection of Trigeminal Schwannomas: 3-Dimensional Operative Video

2019 ◽  
Vol 18 (1) ◽  
pp. E18-E18
Author(s):  
Duarte N C Cândido ◽  
Marcio S Rassi ◽  
Guilherme Henrique Weiler Ceccato ◽  
Jean Gonçalves de Oliveira ◽  
Luis A B Borba
Keyword(s):  
Trigeminal Nerve ◽  
Senior Author ◽  
Petrous Apex ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
3 Dimensional ◽  
History Of ◽  
Nerve Paresis ◽  
Microsurgical Resection ◽  
The Right

Abstract Trigeminal schwannomas are benign lesions arising from the Schwann cells of the trigeminal nerve. This is an unusual tumor that accounts for less than 0.4% of intracranial pathologies, even though they are the second most frequent schwannoma after the vestibular schwannoma. The tumor spreads along the natural course of the V nerve at its cisternal portion, along the ganglion inside Meckel's cave or through its peripheral division. Even though the tumor can reach great size and become multicompartmental. We present a 51-yr-old woman, with an history of 3 mo of incapacitating facial pain, that was found on examination to be on the territory of the third division of the trigeminal nerve on the right side. The MRI depicted a large homogeneous enhancing lesion at the base of the right middle fossa with extension through the petrous apex to the most superior and medial part of the posterior fossa. The patient was operated by the senior author, through a middle fossa approach, dissecting between the two layers of the middle fossa dura (the apparent inner and the true outer layer of the cavernous sinus), the so called middle fossa “peeling”. We achieved total resection of the tumor, but the patient presented after surgery with facial nerve paresis. This is thought to be related to geniculate ganglion manipulation, as it was unprotect by bone at the middle fossa and the patient maintained lacrimal function (post-geniculate alteration). It resolved completely after 6 mo. The patient consented to publication of her images.

scholarly journals Anterior Petrosal Approach for the Resection of a Petrous Apex Meningioma with Tentorial Infiltration

2019 ◽  
Vol 80 (S 03) ◽  
pp. S304-S304
Author(s):  
Diego Mendez-Rosito
Keyword(s):  
Trigeminal Neuralgia ◽  
Free Edge ◽  
Gross Total Resection ◽  
Petrous Apex ◽  
Anatomical Landmarks ◽  
Middle Fossa ◽  
Total Resection ◽  
Middle Fossa Approach ◽  
Anterior Petrosectomy ◽  
Surgical Corridor

Objective The anterior petrosal approach is an extension of the middle fossa approach, characterized by drilling of the posteromedial triangle of the middle fossa. Drilling the Kawase's rhomboid creates a surgical corridor to the posterior fossa after splitting the tentorium. We present a case of a petrous apex meningioma invading the tentorium and causing trigeminal neuralgia. Results The patient was positioned in a Mayfield with the head rotated. A frontotemporal incision was done. A basal craniotomy was done to allow epidural dissection. The anatomical landmarks were identified. The surgical video is analyzed together with cadaveric dissections to highlight landmarks when doing an anterior petrosectomy. The tentorium was identified and the infiltrated region was coagulated and removed. The tentorium was sharply sectioned until the free edge of the tentorium was opened. The tumor in the petrous apex was identified and removed. The trigeminal nerve was decompressed and a gross total resection was achieved with resolution of the symptoms. Conclusion The anterior petrosal approach is a useful corridor to remove tumors in the petrous apex that infiltrate the tentorium. A thorough knowledge of the anatomical landmarks is crucial to identify and delineate the limits of the Kawase's rhomboid. After evaluating different surgical corridors, the anterior petrosal approach allows a gross total resection including the removal of the infiltrated tentorium and a resolution of the symptoms.The link to the video can be found at: https://youtu.be/p4KPUnM_bww.

Microanatomical Study of the Extradural Middle Fossa Approach to the Petroclival and Posterior Cavernous Sinus Region

Neurosurgery ◽  
1994 ◽  
Vol 34 (6) ◽  
pp. 1009-10016 ◽  
Author(s):  
J. Diaz Day ◽  
Takanori Fukushima ◽  
Steven L. Giannotta
Keyword(s):  
Cavernous Sinus ◽  
Middle Fossa ◽  
Middle Fossa Approach
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