Custom-tailored transdural anterior transpetrosal approach to ventral pons and retroclival regions

Steiger, Hans‐Jakob; Hänggi, Daniel; Stummer, Walter; Winkler, Peter

doi:10.3171/jns.2006.104.1.38

Cited by 49 publications

(37 citation statements)

References 29 publications

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“…4H). The subdural anterior petrosectomy has been reported by Steiger et al 24 They reported a subdural anterior petrosectomy as follows: after opening of the basal dura mater, the tentorium is incised behind the entrance of the trochlear nerve toward the SPS, and the dura is stripped from the petrous pyramid. Drilling then starts at the petrous ridge and proceeds laterally and ventrally.…”

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confidence: 99%

Various patterns of the middle cerebral vein and preservation of venous drainage during the anterior transpetrosal approach

Shibao

Toda

Orii

et al. 2016

JNS

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T he superficial middle cerebral vein (SMCV) usually runs inferiorly and anteriorly along the sylvian fissure and leads into the sphenoparietal sinus or directly into the cavernous sinus (CS). 3,5,13,25,27 Hacker classified the SMCV drainage pattern into 4 types: 1) sphenoparietal sinus, 2) sphenobasal vein (SBV), 3) sphenopetrosal vein, and 4) cortical veins with the absence of a definite SMCV. 9The anterior transpetrosal approach (ATPA) is best suited for upper petroclival lesions located anterior and superior to the internal auditory canal and superior to the inferior petrosal sinus.15,16 Epidural procedures and dural incision of the middle temporal fossa in ATPA may interrupt drainage routes from the SMCV.It has been demonstrated that surgical interruption of the SMCV leads to temporal lobe damage. obJective The drainage of the superficial middle cerebral vein (SMCV) has previously been classified into 4 subtypes. Extradural procedures and dural incisions during the anterior transpetrosal approach (ATPA) may interrupt the route of drainage from the SMCV. In this study, the authors examined the relationship between anatomical variations in the SMCV and the corresponding surgical modifications to the ATPA that are necessary for venous preservation. methods This study included 48 patients treated via the ATPA in whom the SMCV was examined using 3D CT venography. The drainage patterns of the SMCV were classified into 3 types: cavernous or absent (Type 1), sphenobasal (Type 2), and sphenopetrosal (Type 3). Type 2 was subdivided into medial (Type 2a) and lateral (Type 2b), and Type 3 was subdivided into vein (Type 3a), vein and sinus (Type 3b), and sinus (Type 3c). The authors performed 3 ATPA modifications to preserve the SMCV: epidural anterior petrosectomy with subdural visualization of the sphenobasal vein (SBV), modification of the dural incision, and subdural anterior petrosectomy. Standard ATPA can be performed with Type 1, Type 2a, and Type 3a drainage. With Type 2b drainage, an epidural anterior petrosectomy with subdural SBV visualization is appropriate. The dural incision should be modified in Type 3b. With Type 3c, a subdural anterior petrosectomy is required. results The frequency of each type was 68.7% (33/48) in Type 1, 8.3% (4/48) in Type 2a, 4.2% (2/48) in Type 2b, 14.6% (7/48) in Type 3a, 2.1% (1/48) in Type 3b, and 2.1% (1/48) in Type 3c. No venous complications were found. coNclusioNs The authors propose an SMCV modified classification based on ATPA modifications required for venous preservation.

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confidence: 99%

Various patterns of the middle cerebral vein and preservation of venous drainage during the anterior transpetrosal approach

Shibao

Toda

Orii

et al. 2016

JNS

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“…55 In our review of the literature, we found 34 cases of posterior circulation aneurysms treated via the standard retrolabyrinthine posterior petrosal approach reported in 14 studies over the course of 2 decades (Table 3). 3,6,11,12,14,22,24,32,40,42,43,50,54,56 All aneurysms were completely occluded. In addition, although early morbidity was high (62%; 41% in the form of cranial nerve deficits), it was often transient.…”

Section: Posterior Petrosal Approachmentioning

confidence: 92%

“…4,23,[28][29][30][31]37,38,56,59 This table provides historical perspective on the application of this approach, spanning 3 decades, as some reports are inclusive of earlier reports from the 1980s. 4,30,31 Aneurysm remnants were reported in 3 cases (11%) after treatment.…”

Section: Historical Perspectivementioning

confidence: 99%

“…7,31 A combined supra-and infratentorial exposure is afforded after dividing the tentorium posterior to the entry of the fourth cranial nerve and ligating and dividing the superior petrosal sinus with a perpendicular dural incision. Although some prefer intradural removal of the petrous apex to tailor the amount of bone removed, 23,56 we prefer the traditional extradural petrous apicectomy as it requires less temporal lobe retraction and poses less risk to the temporal bridging veins. In a thoughtful morphometric analysis, MacDonald et al 37 demonstrated that drilling the petrous apex provided an additional 1-1.5 cm of basilar artery exposure.…”

Section: Historical Perspectivementioning

confidence: 99%

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Petrosal approaches to posterior circulation aneurysms

Gross

Tavanaiepour²,

Du³

et al. 2012

FOC

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Complex posterior circulation aneurysms are formidable lesions with an abysmal natural history. Their management continues to present a challenge to both endovascular and open microsurgical approaches. Affording an expansive, combined supra- and infratentorial exposure, the petrosal approaches are well suited for these challenging lesions when located along the basilar trunk or at a low-lying basilar apex. This report evaluates the evolution and application of petrosal approaches to these lesions. Excluding transsigmoid, infratentorial, or labyrinth-sacrificing approaches, the authors found 23 reports with 61 posterior circulation aneurysms treated via a petrosal approach. Although early morbidity was not negligible, rates of aneurysm occlusion (95% overall) and long-term outcome were quite laudable in light of the challenge posed by these lesions. Moreover, with accumulating experience with petrosal approaches, rates of complications are likely to wane, as neurosurgeons capitalize on the expansive exposure afforded by these indispensable approaches.

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“…1) Various microsurgical approaches for lesions in the anterior part of the pons have been reported, including the anterior petrosal, transcondylar fossa, far lateral, translabyrinthine, transcochlear, and transoral transclival approaches. 1,3,12,14,17,21) In this case, the trans-fourth ventricular floor approach for cavernoma in the pontine tegmentum is most suitable as the lesion is shallowest with this approach, but the choice of approach for ventral cavernoma is debatable. We selected the approach through the former removal route via the trans-fourth ventricular floor for the ventral pontine cavernoma for the following reasons: location in the lower pons, left corticospinal tract issing'' Brainstem Cavernous Angiomas compressed by the lesion laterally, adjacent to the previous removal cavity, and in the same approach direction as the resected lesion.…”

Section: Discussionmentioning

confidence: 99%

"Kissing" Brainstem Cavernous Angiomas Removed Using a Trans-Fourth Ventricular Floor Approach -Case Report-

Murata

Horiuchi

Hanaoka

et al. 2011

Neurol. Med. Chir.(Tokyo)

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A 39-year-old woman presented with a rare case of``kissing'' brainstem cavernomas formed by separate lesions enlarging with simultaneous recurrent hemorrhages, which was successfully treated by staged resection using a trans-fourth ventricular floor approach. She had a familial history of cerebral cavernous angioma, and presented with a history of four episodes of sudden neurological deterioration. Magnetic resonance (MR) imaging obtained at each neurological event demonstrated two distinct brainstem cavernomas located in the pontine tegmentum and ventral part of the lower pons, both of which enlarged stepwise caused by simultaneous recurrent hemorrhages. Both cavernomas contacted and formed``kissing'' lesions. She underwent midline suboccipital craniotomy in the prone position. The cavernoma in the pontine tegmentum was resected through a trans-fourth ventricular floor approach. Although``kissing'' formation appeared on preoperative MR imaging, parenchyma was identified at the bottom of the removal cavity of the dorsal lesion, and resection was terminated. MR imaging following the first surgery revealed complete resection of the pontine tegmentum cavernoma and the ventral pontine cavernoma, which was located adjacent to the bottom of the removal cavity and aligned in same direction along the fourth ventricular floor approach. At 10 days after first surgery, she underwent the same procedure with the aid of neuronavigation to resect the ventral pontine cavernoma through the former removal cavity. This approach through the previous removal route, particularly for resection of`k issing'' lesions which are difficult to access in the brainstem, is a technically feasible microsurgical procedure.

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Custom-tailored transdural anterior transpetrosal approach to ventral pons and retroclival regions

Abstract: The custom-made transdural anterior petrosectomy appears to be a feasible alternative to the formal extradural approach.

Cited by 49 publications

References 29 publications

Various patterns of the middle cerebral vein and preservation of venous drainage during the anterior transpetrosal approach

Various patterns of the middle cerebral vein and preservation of venous drainage during the anterior transpetrosal approach

Petrosal approaches to posterior circulation aneurysms

"Kissing" Brainstem Cavernous Angiomas Removed Using a Trans-Fourth Ventricular Floor Approach -Case Report-

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