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Transpetrosal approach for craniobasal tumors. Experience of 220 cases
Technology - SurgicalApproaches and Endoscopy
Monday, 7 July 1997
I0-7-951
Transpetrosal approach for craniobasal tumors. Experience of 220 cases
Detailsof technique and results will be discussedalong with a review of the literature.
Akira Hakuba, Kenji Ohata, Kenji Nagai,Michiharu Morino, Dept. of Neurosurgery, OsakaCity University, Osaka, Japan 1
Introduction: Since 1973, 220 transpetrosal approaches, for various craniobasal lesionsin the CP angle, clivus and suprasellar areas, have been performed. Method: Therewere 127 femaleand 93 maleswith agesranging between 2 and 73years (mean50.4 yrs).Thereare four kindsof transpetrosal approaches; 1) transmastoideal, 2) transzygomatic, 3) combined 1 and 2, 4) oticocondylar approaches. The selection of a particular approach will depend on the location and size of the lesion. Total removal of tumors in the transpetrosal approach was accomplished in 64% of 73 meningiomas, 95% of 64 neurinomas, 95% of 22 craniopharyngiomas, 74% of 19 pituitaryadenomas and 73% of 11 chordomas. The outcome was excellent in 31, good in 167, poor in 10 and death in 12 with operative mortalitys outot 220 (2.7%). Hearing waspreserved 41% in 171. The complications were CSF leakage in 8, cerebral contusion in 18, infarction in 5, and meningitis in 6, etc. Discussion and Conclusion: The transpetrosal approach can be useful to minimize brain retraction and achieve optimal exposure with the shortest possible distance and the most adequate view angle in the suprasellar, c1ival and petroclival regions. In this approach, hearing may be preserved because the middle ear vestibule and cochlear can be left intact during removal of the petrous bone.
10-7-961 The retrosigmoid intradural petrous apex approach (RIPA)to Meckel's cave and middle fossa M. Tatagiba, G.A. Carvalho, M. Samii. Department of Neurosurgery, Nordstadt Hospital, Hannover, Germany Introduction: The authorspresent a modification of the standard retrosigmoid intradural route to cerebellopontine (CPA) tumors which extend into Meckel's cave and the middle cranial fossa. This approach is called by the authors "Retrosigmoid Intradural PetrousApexApproach" (RIPA). Thesurgical anatomy of the RIPAis presented along with clinical examples. Methods: Main steps for the RIPA include a standard retrosigmoid craniotomy, intradural exposure of CPA,drilling the petrous apex portion to expose the Vthnervewithinthe Meckel'scave,andopening the tentorium upto Meckel's cave. The RIPA has been routinelyused in our Department since 1994.A total of 16 patients harboring meningiomas and trigeminal schwannomas which affected the middle and posteriorfossae and Meckel'scave have been operated on usingthis approach. The surgicalanatomyis described by cadaveric dissection, and the 16 clinical cases are reviewed. Clinicaland operative records, as well as radiological findings and postoperative outcome are presented. ReSUlts: Total tumor resection with preservation of the cranial nerves V, VII, VIII was achieved in the majority of the cases. No mortality and minimal morbidity characterized this series. Conclusion: The RIPAallowed for resection of large tumors from the posteriorfossa up to the middlefossa usinga simpleapproach withoutnecessity of extensive transpetrosal exposures. Facial and cochlearnervesare well visualized and preservedin the majorityof the cases.
I0-7-971
Reappraisal of the infratentorial supracerebellar approach
Y.Yonekawa, 1.E. Kwak, E. Taub. Department of Neurosurgery, Neurosurgical University Clinic, Zurich, Switzerland The infratentorial supracerebellar approach (ISCLA) is suitablefor the removal of tumorsin the pineal region. It can also be usedfor pathology of the thalamic, midbrain-tectal, tegmento-pontine and cerebellar regions. During the last 3 years, 29 patients underwent this approach in the sitting position: 22 usual medianISCLAand 7 paramedian ISCLA(Yasargil). Total removal of pathology was accomplished in 20 cases and partial or subtotal removal in 9 cases. No mortality and two cases of neurological deterioration were observed: one hemiparesis with 'thalamic hand" in one patient, and persistent Parinaud's syndrome in one patient. The followingprincipal observations can be madefrom our experience: (1) Pineal and thalamic pathology should be submitted to the usual median ISCLA. (2) Unilateral colliculo-midbrain pathology and tegmento-pontine pathology shouldbe submittedto paramedian ISeA. (3) Removal of a colliculussuperioron one side does not seemto produce any disturbance of occular movement. (4) Neither procedure gives adequate access to pathology of the floor of the third ventricle, so that an invasiveprocedure such as divisionof the colliculi in the midline mightbe taken into consideration.
S23
0-7-981 Pericollicular surgical approaches to pons and medulla oblongata
·C.Strauss, J. Romstock, R. Fahlbusch. Department of Neurosurgery, University of Erlangen-Nuremberg, 91054Erlangen, Germany Introduction: Safe surgical approaches into the floor of the IVth ventricle in brainstem lesionsare basedon detailedknowledge of rhomboid fossa anatomy and intraoperative localisation of superficial nuclei andfibers. Methods: For morphometric analysis 12 brainstem specimens were investigated in conventional axial and sagittal histological slices. Motor nuclei and fibers of the rhomboid fossa were measured in all 3 dimensions with consideration of shrinkage factors. During surgery electrical stimulation of superficial cranial nerve nuclei V-XII was performed in 40 patientswith intraaxial lesions and lesionsinfiltrating the brainstem. Results: Morphometric analysisof rhomboid fossa anatomydefinesa paramedian infracollicular approach of 9.2 mm locatedbetween the facial colliculus and the upperpole of the Nucleus N. hypoglossi. A paramedian supracollicular approach betweenfacialcolliculus and the fibers of the Vlth cranialnerve within the medullary velum measures 13.8 mm. Morphometric data were transferred to the surgical field by direct electrical stimulation of cranial motor nuclei and fibersV-XII in a total of 40 patients. Localisation of facial colliculusand trigonum hypoglossi was achieved in all cases. No side effectswere observed. Discussion: Morphometric investigation of histological anatomydefinestwo operative approaches intothe rhomboid fossa. Morphometric data can be transferred to surgeryusingadvanced neurophysiological methods. Direct electrical stimulation is a reliable, fast and safe methodto localizefunctionally important landmarks, thusprovidinq a safeapproach for lesionswithinthe rhomboid fossa. [1] Langet al: Acta Neurochir 113,84-90,1991 [2] Strauss et al~ J Neurosurg 79, 393--399, 1993
10-7-991 Tec.hnicalaspects ofthe IV ventricle mapping during bratnstem surgery G.A. Schekutiev, V.1. Lukianov, A.Y. Lubnin. N.N. Burdenko Neurosurgical Institute, Moscow, Russia Themoderntechnique of brainstem tumorsurgeryis basedon approachthrough safe entry zones via the floor of the IV ventricle. These zones can be identified by electrical stimulation of the floor and evokedelectromyographic (EMG) recordings of muscles of the head. In 20 patients with glioma and cavemoma of the caudal brain stem we studied technical aspectsof this IV ventricle mapping. Stimulating techniques: constant current versusconstantvoltage; types of electrodes: bipolar forceps, monopolar probe, coaxial electrode; types of insulationof the electrode: flush tip versus bare tip were compared. EMG electrodes from muscles supplied by the VII, IX, X, XII cranialnervesof both sides wereconnected simultaneously to the two channel amplifier. It allowed us to find EMG response free areas of the floor of the IV ventricle, that is the safe entry zone. Howevera variant of mixed EMGrecording does not allowto attributeany EMG response to definite motor structure of the brain stem. The results that the best technique for mapping of motor structures of the brain stem is constant current stimulation by flush tip coaxial electrode with a bipolar regime. In 14 patients we could get EMG response during stimulation of the hypoglossal and facial triangles of the rhomboid fossa from both left and right sides. In the other 6 cases identification of motor structures was partiallysuccessful. In 4 cases of them it probablydepended on displacement of motor structures and in 2 cases there was severe preoperative deficit of the corresponding motorfunctions.
I0-7-100 I malignant Rec.onstructive surg~ry of skull base region after tumor excision Igor V. Reshetov 1, ValeryI. Chissov1 , Alexander M. Sdvizkov 1 , Sergey A. Kravtzov j, Oleg V. Matorin1, SergeyV.Tanyashin 2, Vasiliy A. Tcherekaev 2. 1 p.A. Hertzen CancerResearch Institute, Moscow, Russia, 2 Burdenko Neurosurgical Institute, Moscow, Russia We haveoperated 38 patientsfor spread(T3-T4) tumorswith reconstruction of craniomaxillofacial region. There were epidermoid and basal cell carcinomas, sarcomas andsomeothermalignancies. Inall the caseswe used rotatedor vascularized free tissue flaps: in 21 cases fascilocutaneous (from forearm, parascapular region or forehead), in 12 cases musculofascial (m. latissimus dorsi, m. serratus anterior and m. trapezium), in remaining 5 cases - vascularized omental flap. Complication rate was 30%, in 2 caseswe observed insufficiency of vascularanastomoses. Therewas no postoperative mortality. 3-yearmortality
Monday, 7 July 1997
I0-7-951
Transpetrosal approach for craniobasal tumors. Experience of 220 cases
Detailsof technique and results will be discussedalong with a review of the literature.
Akira Hakuba, Kenji Ohata, Kenji Nagai,Michiharu Morino, Dept. of Neurosurgery, OsakaCity University, Osaka, Japan 1
Introduction: Since 1973, 220 transpetrosal approaches, for various craniobasal lesionsin the CP angle, clivus and suprasellar areas, have been performed. Method: Therewere 127 femaleand 93 maleswith agesranging between 2 and 73years (mean50.4 yrs).Thereare four kindsof transpetrosal approaches; 1) transmastoideal, 2) transzygomatic, 3) combined 1 and 2, 4) oticocondylar approaches. The selection of a particular approach will depend on the location and size of the lesion. Total removal of tumors in the transpetrosal approach was accomplished in 64% of 73 meningiomas, 95% of 64 neurinomas, 95% of 22 craniopharyngiomas, 74% of 19 pituitaryadenomas and 73% of 11 chordomas. The outcome was excellent in 31, good in 167, poor in 10 and death in 12 with operative mortalitys outot 220 (2.7%). Hearing waspreserved 41% in 171. The complications were CSF leakage in 8, cerebral contusion in 18, infarction in 5, and meningitis in 6, etc. Discussion and Conclusion: The transpetrosal approach can be useful to minimize brain retraction and achieve optimal exposure with the shortest possible distance and the most adequate view angle in the suprasellar, c1ival and petroclival regions. In this approach, hearing may be preserved because the middle ear vestibule and cochlear can be left intact during removal of the petrous bone.
10-7-961 The retrosigmoid intradural petrous apex approach (RIPA)to Meckel's cave and middle fossa M. Tatagiba, G.A. Carvalho, M. Samii. Department of Neurosurgery, Nordstadt Hospital, Hannover, Germany Introduction: The authorspresent a modification of the standard retrosigmoid intradural route to cerebellopontine (CPA) tumors which extend into Meckel's cave and the middle cranial fossa. This approach is called by the authors "Retrosigmoid Intradural PetrousApexApproach" (RIPA). Thesurgical anatomy of the RIPAis presented along with clinical examples. Methods: Main steps for the RIPA include a standard retrosigmoid craniotomy, intradural exposure of CPA,drilling the petrous apex portion to expose the Vthnervewithinthe Meckel'scave,andopening the tentorium upto Meckel's cave. The RIPA has been routinelyused in our Department since 1994.A total of 16 patients harboring meningiomas and trigeminal schwannomas which affected the middle and posteriorfossae and Meckel'scave have been operated on usingthis approach. The surgicalanatomyis described by cadaveric dissection, and the 16 clinical cases are reviewed. Clinicaland operative records, as well as radiological findings and postoperative outcome are presented. ReSUlts: Total tumor resection with preservation of the cranial nerves V, VII, VIII was achieved in the majority of the cases. No mortality and minimal morbidity characterized this series. Conclusion: The RIPAallowed for resection of large tumors from the posteriorfossa up to the middlefossa usinga simpleapproach withoutnecessity of extensive transpetrosal exposures. Facial and cochlearnervesare well visualized and preservedin the majorityof the cases.
I0-7-971
Reappraisal of the infratentorial supracerebellar approach
Y.Yonekawa, 1.E. Kwak, E. Taub. Department of Neurosurgery, Neurosurgical University Clinic, Zurich, Switzerland The infratentorial supracerebellar approach (ISCLA) is suitablefor the removal of tumorsin the pineal region. It can also be usedfor pathology of the thalamic, midbrain-tectal, tegmento-pontine and cerebellar regions. During the last 3 years, 29 patients underwent this approach in the sitting position: 22 usual medianISCLAand 7 paramedian ISCLA(Yasargil). Total removal of pathology was accomplished in 20 cases and partial or subtotal removal in 9 cases. No mortality and two cases of neurological deterioration were observed: one hemiparesis with 'thalamic hand" in one patient, and persistent Parinaud's syndrome in one patient. The followingprincipal observations can be madefrom our experience: (1) Pineal and thalamic pathology should be submitted to the usual median ISCLA. (2) Unilateral colliculo-midbrain pathology and tegmento-pontine pathology shouldbe submittedto paramedian ISeA. (3) Removal of a colliculussuperioron one side does not seemto produce any disturbance of occular movement. (4) Neither procedure gives adequate access to pathology of the floor of the third ventricle, so that an invasiveprocedure such as divisionof the colliculi in the midline mightbe taken into consideration.
S23
0-7-981 Pericollicular surgical approaches to pons and medulla oblongata
·C.Strauss, J. Romstock, R. Fahlbusch. Department of Neurosurgery, University of Erlangen-Nuremberg, 91054Erlangen, Germany Introduction: Safe surgical approaches into the floor of the IVth ventricle in brainstem lesionsare basedon detailedknowledge of rhomboid fossa anatomy and intraoperative localisation of superficial nuclei andfibers. Methods: For morphometric analysis 12 brainstem specimens were investigated in conventional axial and sagittal histological slices. Motor nuclei and fibers of the rhomboid fossa were measured in all 3 dimensions with consideration of shrinkage factors. During surgery electrical stimulation of superficial cranial nerve nuclei V-XII was performed in 40 patientswith intraaxial lesions and lesionsinfiltrating the brainstem. Results: Morphometric analysisof rhomboid fossa anatomydefinesa paramedian infracollicular approach of 9.2 mm locatedbetween the facial colliculus and the upperpole of the Nucleus N. hypoglossi. A paramedian supracollicular approach betweenfacialcolliculus and the fibers of the Vlth cranialnerve within the medullary velum measures 13.8 mm. Morphometric data were transferred to the surgical field by direct electrical stimulation of cranial motor nuclei and fibersV-XII in a total of 40 patients. Localisation of facial colliculusand trigonum hypoglossi was achieved in all cases. No side effectswere observed. Discussion: Morphometric investigation of histological anatomydefinestwo operative approaches intothe rhomboid fossa. Morphometric data can be transferred to surgeryusingadvanced neurophysiological methods. Direct electrical stimulation is a reliable, fast and safe methodto localizefunctionally important landmarks, thusprovidinq a safeapproach for lesionswithinthe rhomboid fossa. [1] Langet al: Acta Neurochir 113,84-90,1991 [2] Strauss et al~ J Neurosurg 79, 393--399, 1993
10-7-991 Tec.hnicalaspects ofthe IV ventricle mapping during bratnstem surgery G.A. Schekutiev, V.1. Lukianov, A.Y. Lubnin. N.N. Burdenko Neurosurgical Institute, Moscow, Russia Themoderntechnique of brainstem tumorsurgeryis basedon approachthrough safe entry zones via the floor of the IV ventricle. These zones can be identified by electrical stimulation of the floor and evokedelectromyographic (EMG) recordings of muscles of the head. In 20 patients with glioma and cavemoma of the caudal brain stem we studied technical aspectsof this IV ventricle mapping. Stimulating techniques: constant current versusconstantvoltage; types of electrodes: bipolar forceps, monopolar probe, coaxial electrode; types of insulationof the electrode: flush tip versus bare tip were compared. EMG electrodes from muscles supplied by the VII, IX, X, XII cranialnervesof both sides wereconnected simultaneously to the two channel amplifier. It allowed us to find EMG response free areas of the floor of the IV ventricle, that is the safe entry zone. Howevera variant of mixed EMGrecording does not allowto attributeany EMG response to definite motor structure of the brain stem. The results that the best technique for mapping of motor structures of the brain stem is constant current stimulation by flush tip coaxial electrode with a bipolar regime. In 14 patients we could get EMG response during stimulation of the hypoglossal and facial triangles of the rhomboid fossa from both left and right sides. In the other 6 cases identification of motor structures was partiallysuccessful. In 4 cases of them it probablydepended on displacement of motor structures and in 2 cases there was severe preoperative deficit of the corresponding motorfunctions.
I0-7-100 I malignant Rec.onstructive surg~ry of skull base region after tumor excision Igor V. Reshetov 1, ValeryI. Chissov1 , Alexander M. Sdvizkov 1 , Sergey A. Kravtzov j, Oleg V. Matorin1, SergeyV.Tanyashin 2, Vasiliy A. Tcherekaev 2. 1 p.A. Hertzen CancerResearch Institute, Moscow, Russia, 2 Burdenko Neurosurgical Institute, Moscow, Russia We haveoperated 38 patientsfor spread(T3-T4) tumorswith reconstruction of craniomaxillofacial region. There were epidermoid and basal cell carcinomas, sarcomas andsomeothermalignancies. Inall the caseswe used rotatedor vascularized free tissue flaps: in 21 cases fascilocutaneous (from forearm, parascapular region or forehead), in 12 cases musculofascial (m. latissimus dorsi, m. serratus anterior and m. trapezium), in remaining 5 cases - vascularized omental flap. Complication rate was 30%, in 2 caseswe observed insufficiency of vascularanastomoses. Therewas no postoperative mortality. 3-yearmortality