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.

Revascularization of the Posterior Inferior Cerebellar Artery Using the Occipital Artery: A Cadaveric Study Comparing the p3 and p1 Recipient Sites

2020 ◽  
Vol 19 (2) ◽  
pp. E122-E129 ◽  
Author(s):  
Peyton L Nisson ◽  
Xinmin Ding ◽  
Ali Tayebi Meybodi ◽  
Ryan Palsma ◽  
Arnau Benet ◽  
...  
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Median Number ◽  
Cerebellar Tonsil ◽  
Occipital Artery ◽  
Recipient Site ◽  
Cerebellar Artery ◽  
Feasible Alternative ◽  
End To End ◽  
Lower Cranial Nerves

Abstract BACKGROUND Revascularization of the posterior inferior cerebellar artery (PICA) is typically performed with the occipital artery (OA) as an extracranial donor. The p3 segment is the most accessible recipient site for OA-PICA bypass at its caudal loop inferior to the cerebellar tonsil, but this site may be absent or hidden due to a high-riding location. OBJECTIVE To test our hypothesis that freeing p1 PICA from its origin, transposing the recipient into a shallower position, and performing OA-p1 PICA bypass with an end-to-end anastomosis would facilitate this bypass. METHODS The OA was harvested, and a far lateral craniotomy was performed in 16 cadaveric specimens. PICA caliber and number of perforators were measured at p1 and p3 segments. OA-p3 PICA end-to-side and OA-p1 PICA end-to-end bypasses were compared. RESULTS OA-p1 PICA bypass with end-to-end anastomosis was performed in 16 specimens; whereas, OA-p3 PICA bypass with end-to-side anastomosis was performed in 11. Mean distance from OA at the occipital groove to the anastomosis site was shorter for p1 than p3 segments (30.2 vs 48.5 mm; P < .001). Median number of perforators on p1 was 1, and on p3, it was 4 (P < .001). CONCLUSION Although most OA-PICA bypasses can be performed using the p3 segment as the recipient site for an end-to-side anastomosis, a more feasible alternative to conventional OA-p3 PICA bypass in cases of high-riding caudal loops or aberrant anatomy is to free the p1 PICA, transpose it away from the lower cranial nerves, and perform an end-to-end OA-p1 PICA bypass instead.

scholarly journals Technical strategies to approach aneurysms of the vertebral and posterior inferior cerebellar arteries

2005 ◽  
Vol 19 (2) ◽  
pp. 1-5 ◽  
Author(s):  
Niklaus Krayenbühl ◽  
Carlos A. Guerrero ◽  
Ali F. Krisht
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Anatomical Location ◽  
Microsurgical Anatomy ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Pica Aneurysms ◽  
Lower Cranial Nerves

Object Aneurysms of the vertebral artery (VA) and proximal posterior inferior cerebellar artery (PICA) are rare and challenging lesions, as they are located in front of the brainstem and surrounded by the lower cranial nerves. Many different approaches have been described for their treatment, and have yielded different results. With the use of different examples of lesions, the authors describe their surgical strategy in the management of VA and PICA aneurysms. Methods The far-lateral approach was used, and the potential of its different extensions according to the specific anatomical location and configuration of different types of aneurysms is emphasized. Conclusions With the present knowledge of the microsurgical anatomy in the region of the foramen magnum, the far-lateral approach can be tailored to the specific anatomical and morphological configuration of an aneurysm in this region with good surgical results.

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.

Surgical clipping of a ruptured posterior inferior cerebellar artery aneurysm

2015 ◽  
Vol 38 (videosuppl1) ◽  
pp. Video12
Author(s):  
M. Yashar S. Kalani ◽  
Peter Nakaji ◽  
Joseph M. Zabramski ◽  
Robert F. Spetzler
Keyword(s):  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Artery Aneurysm ◽  
Posterior Circulation ◽  
Endovascular Techniques ◽  
Surgical Clipping ◽  
Cerebellar Artery ◽  
Posterior Circulation Aneurysms ◽  
Pica Aneurysms ◽  
Lower Cranial Nerves

Posterior circulation aneurysms are commonly treated with endovascular techniques. In select cases, microsurgery remains an essential tool for treating these lesions. We present a case of a ruptured posterior inferior cerebellar artery (PICA) aneurysm approached via a craniotomy. Given the labyrinth of neurovascular bundles present in the posterior fossa, surgical exposure of PICA aneurysms can be challenging. This video demonstrates the steps of the craniotomy, subarachnoid dissection, mobilization of the vertebral artery and lower cranial nerves, and clipping of the aneurysm.The video can be found here: http://youtu.be/fQSxQj7oL0U.

scholarly journals Far Lateral Craniotomy for Resection of Foramen Magnum Meningioma

2019 ◽  
Vol 80 (S 04) ◽  
pp. S355-S357
Author(s):  
Robert T. Wicks ◽  
Xiaochun Zhao ◽  
Celene B. Mulholland ◽  
Peter Nakaji
Keyword(s):  
Cranial Nerves ◽  
Craniocervical Junction ◽  
Foramen Magnum ◽  
Occipital Condyle ◽  
Formidable Challenge ◽  
Close Proximity ◽  
Vertebrobasilar Circulation ◽  
Far Lateral ◽  
Lower Cranial Nerves ◽  
Gain Access

Abstract Objective Foramen magnum meningiomas present a formidable challenge to resection due to frequent involvement of the lower cranial nerves and vertebrobasilar circulation. The video shows the use of a far lateral craniotomy to resect a foramen magnum meningioma. Design, Setting, and Participant A 49-year-old woman presented with neck pain and was found to have a large foramen magnum meningioma (Fig. 1A, B). Drilling of the posterior occipital condyle was required to gain access to the lateral aspect of the brain stem. The amount of occipital condyle resection varies by patient and pathology. Outcome/Result Maximal total resection of the tumor was achieved (Fig. 1B, C), and the patient was discharged on postoperative day 4 with no neurologic deficits. The technique for tumor microdissection (Fig. 2) is shown in the video. Conclusion Given the close proximity of foramen magnum meningiomas to vital structures at the craniocervical junction, surgical resection with careful microdissection and preservation of the overlying dura to prevent postoperative pseudomeningocele is necessary to successfully manage this pathology in those patients who are surgical candidates.The link to the video can be found at: https://youtu.be/Mds9N1x2zE0.

Microvascular decompression for hemifacial spasm

1991 ◽  
Vol 75 (3) ◽  
pp. 388-392 ◽  
Author(s):  
Shinji Nagahiro ◽  
Akira Takada ◽  
Yasuhiko Matsukado ◽  
Yukitaka Ushio
Keyword(s):  
Hemifacial Spasm ◽  
Microvascular Decompression ◽  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Anterior Inferior Cerebellar Artery ◽  
Vascular Compression ◽  
Content Type ◽  
Seventh Cranial Nerve ◽  
Cerebellar Artery

✓ To determine the causative factors of unsuccessful microvascular decompression for hemifacial spasm, the follow-up results in 53 patients were assessed retrospectively. The mean follow-up period was 36 months. There were 32 patients who had compression of the seventh cranial nerve ventrocaudally by an anterior inferior cerebellar artery (AICA) or a posterior inferior cerebellar artery. Of these 32 patients, 30 (94%) had excellent postoperative results. Of 14 patients with more severe compression by the vertebral artery, nine (64%) had excellent results, three (21%) had good results, and two (14%) had poor results; in this group, three patients with excellent results experienced transient spasm recurrence. There were seven patients in whom the meatal branch of the AICA coursed between the seventh and eighth cranial nerves and compressed the dorsal aspect of the seventh nerve; this was usually associated with another artery compressing the ventral aspect of the nerve (“sandwich-type” compression). Of these seven patients, five (71%) had poor results including operative failure in one and recurrence of spasm in four. The authors conclude that the clinical outcome was closely related to the patterns of vascular compression.

scholarly journals The role of alternative anastomosis sites in occipital artery–posterior inferior cerebellar artery bypass in the absence of the caudal loop using the far-lateral approach

2017 ◽  
Vol 126 (2) ◽  
pp. 634-644 ◽  
Author(s):  
Hitoshi Fukuda ◽  
Alexander I. Evins ◽  
Koichi Iwasaki ◽  
Itaro Hattori ◽  
Kenichi Murao ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Posterior Inferior Cerebellar Artery ◽  
Technical Difficulty ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Difficulty Level ◽  
Occipital Artery ◽  
Cerebellar Artery ◽  
Far Lateral Approach ◽  
Far Lateral

OBJECTIVE Occipital artery–posterior inferior cerebellar artery (OA-PICA) bypass is a technically challenging procedure for posterior fossa revascularization. The caudal loop of the PICA is considered the optimal site for OA-PICA anastomosis, however its absence can increase the technical difficulty associated with this procedure. The use of the far-lateral approach for accessing alternative anastomosis sites in OA-PICA bypass in patients with absent or unavailable caudal loops of PICA is evaluated. METHODS A morphometric analysis of OA-PICA bypass with anastomosis on each segment of the PICA was performed on 5 cadaveric specimens through the conventional midline foramen magnum and far-lateral approaches. The difficulty level associated with anastomoses at each segment was qualitatively assessed in each approach for exposure and maneuverability by multiple surgeons. A series of 8 patients who underwent OA-PICA bypass for hemodynamic ischemia or ruptured dissecting posterior fossa aneurysms are additionally reviewed and described, and the clinical significance of the caudal loop of PICA is discussed. RESULTS Anastomosis on the caudal loop could be performed more superficially than on any other segment (p < 0.001). A far-lateral approach up to the medial border of the posterior condylar canal provided a 13.5 ± 2.2–mm wider corridor than the conventional midline foramen magnum approach, facilitating access to alternative anastomosis sites. The far-lateral approach was successfully used for OA-PICA bypass in 3 clinical cases whose caudal loops were absent, whereas the midline foramen magnum approach provided sufficient exposure for caudal loop bypass in the remaining 5 cases. CONCLUSIONS The absence of the caudal loop of the PICA is a major contributing factor to the technical difficulty of OA-PICA bypass. The far-lateral approach is a useful surgical option for OA-PICA bypass when the caudal loop of the PICA is unavailable.

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.

scholarly journals Anterior Inferior Cerebellar Aneurysm Treated by Aneurysm Resection and Intracranial Artery Anastomosis in situ: A Case Report and Literature Review

2021 ◽  
Vol 8 ◽  
Author(s):  
Chaojue Huang ◽  
Shixing Qin ◽  
Wei Huang ◽  
Yongjia Yu
Keyword(s):  
Surgical Treatment ◽  
Posterior Inferior Cerebellar Artery ◽  
Cranial Nerves ◽  
Anterior Inferior Cerebellar Artery ◽  
Intracranial Artery ◽  
Disturbance Of Consciousness ◽  
Cerebellar Artery ◽  
Wide Range ◽  
Aneurysm Resection

Background: Anterior inferior cerebellar artery (AICA) aneurysms are relatively rare in clinical practice, accounting for &lt;1% of all intracranial arteries. After the diagnosis and location are confirmed by angiography, magnetic resonance, and other imaging examinations, interventional, or surgical treatment is often used, but some complex aneurysms require reconstructive surgery.Case Description: An 8-year-old male child was admitted to the hospital due to sudden disturbance of consciousness for 2 weeks. The head CT showed hematocele in the ventricular system with subarachnoid hemorrhage in the basilar cistern and annular cistern. On admission, he was conscious, answered correctly, had a soft neck, limb muscle strength was normal, and had no cranial nerves or nervous system abnormalities. A preoperative examination showed the right side of the anterior distal arteries class under the circular wide neck aneurysm, the distal anterior inferior cerebellar artery supplying a wide range of blood to the cerebellum, the ipsilateral posterior inferior cerebellar artery absent, and the aneurysm close to the VII, VIII nerves. The aneurysm was successfully treated by aneurysm resection and intracranial artery anastomosis in situ of a2 AICA-a2 AICA.Conclusions: AICA aneurysms are relatively rare; in this case, a complex wide-necked aneurysm was successfully treated by aneurysm resection and anastomosis in situ of a2 AICA-a2 AICA. This case can provide a reference for the surgical treatment of complex anterior cerebellar aneurysms.

Sign in / Sign up

Export Citation Format

Share Document