Anterior transpetrosal approach 1 1 Anterior Transpetrosal Approach Tips and Complications Michihiro Kohno, M.D., Ph.D. 1 1 Department of Neurosurgery

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1 Anterior transpetrosal approach 1 1 Anterior Transpetrosal Approach Tips and Complications Michihiro Kohno, M.D., Ph.D. 1 1 Department of Neurosurgery & Stroke Center, Tokyo Metropolitan Police Hospital The anterior transpetrosal approach is a skull base approach that is used for treating lesions in the cerebellopontine angle or pre pontine area. Trigeminal schwannomas and tentorial meningiomas extending to the Meckel s cave are good indications for this surgical approach. This approach is also applicable for basilar trunk aneurysms and pontine cavernomas or gliomas. The weak points of this approach are a narrow and deep operative field, the necessity of temporal lobe retraction, and a limited lesion site for manipulation this surgical approach is not appropriate for lesions located around the lower cranial nerves. Complications such as temporal lobe problems are concerns for surgeons during this procedure therefore, lumbar drainage and or controlling brain retractors are recommended for preventing these difficulties. Given that performance of the anterior transpetrosal approach requires skillful skull base techniques and mastery of methods to prevent complications, this surgical approach is not considered easy. Therefore, surgeons who perform this approach must have adequate knowledge of surgical anatomy so as not to be disoriented during surgery they must also be aware of potential complications and how to avoid them. Received May 31, 2012 accepted June 13, 2012 Key words anterior transpetrosal approach, middle cranial fossa, Meckel s cave, skull base, trigeminal schwannoma Jpn J Neurosurg Tokyo , 2012 S 2 mastoidectomy posterior transpetrosal approach transmastoid approach presigmoid approach retrolabyrinthine approach translabyrinthine approach / middle fossa approach petrous apex anterior transpetrosal approach posterior transpetrosal approach anterior Address reprint requests to Michihiro Kohno, M.D., Ph.D., Department of Neurosurgery & Stroke Center, Tokyo Metropolitan Police Hospital, Nakano, Nakano ku, Tokyo , Japan

2 4 1 Lateral suboccipital 95 Transmastoid Middle fossa anterior transpetrosal Vestibular schwannomas n Lateral suboccipital Transmastoid 33 Middle fossa anterior transpetrosal Transcondylar Other cerbellopontine angle tumors n approaches Combination n 101 combined petrosal approach n 45 Fig. 1 Selection of surgical approaches for cerebellopontine angle tumors at Tokyo Metropolitan Police Hospital Upper vestibular schwannomas. Lower other cerebellopontine angle tumors. Note that various approaches were used in nearly equal frequency for cerebellopontine angle tumors excluding vestibular schwannomas, in which the lateral suboccipital approach was mainly used. transpetrosal approach combined petrosal approach 2 anterior transpetrosal approach Meckel N Anterior transpetrosal approach ATP 893 N lateral suboccipital approach N anterior transpetrosal approach middle fossa approach Fig. 1 2 Meckel Jpn J Neurosurg VOL. 21 NO

Fig. 2 Anterior transpetrosal approach ATP and

superficial petrosal nerve, IAC internal auditory

cochlea, SSC superior semicircular canal 3 Meckel N

/ 20 Meckel lateral suboccipital approach Meckel

petrosal approach anterior transpetrosal approach

3 GSPN GSPN Co MF ATP IAC AE SSC Anterior transpetrosal approach ATP Middle fossa approach MF Fig. 2 Anterior transpetrosal approach ATP and middle fossa approach MF right side GSPN greater superficial petrosal nerve, IAC internal auditory canal, AE arcuate eminence, Co. cochlea, SSC superior semicircular canal 3 Meckel N anterior transpetrosal approach Meckel / 20 Meckel lateral suboccipital approach Meckel anterior transpetrosal approach Meckel combined petrosal approach anterior transpetrosal approach 21 4 Middle fossa approach MF Fig. 2 MF ATP MF Fig. 2 MF N N ATP N

A B C Burr holes craniotomy D Burr holes craniotomy E Burr holes craniotomy Mastoidectomy Skin incision

3 Positioning and skin incision right side Upper park bench position A, B.

1 Fig. 3 20 30 supine lateral position pericranial flap Fig.

suture Sigmoid sinus Asterion Supramastoid crest Lambdoid suture Squamosal suture Parietomastoid suture

4 A B C Burr holes craniotomy D Burr holes craniotomy E Burr holes craniotomy Mastoidectomy Skin incision Skin incision Skin incision Burr holes Anterior transpetrosal approach Combined petrosal approach Fig. 3 Positioning and skin incision right side Upper park bench position A, B. Lower skin incisions for the anterior transpetrosal approach C, D and the combined petrosal approach E. 1 Fig supine lateral position pericranial flap Fig. 3C Burr holes Root of Zygoma External acoustic meatus Spine of Henle Mastoid process Occipitomastoid suture Sigmoid sinus Asterion Supramastoid crest Lambdoid suture Squamosal suture Parietomastoid suture Fig. 4 Craniotomy in the anterior transpetrosal approach right side 2 root of zygoma Fig. 4 / / greater superficial petrosal nerve GSPN GSPN / arcuate eminence Jpn J Neurosurg VOL. 21 NO

dura SPS BA Area for drilling in anterior transpetrosal approach ICA SCA Fig.

MMA middle meningeal artery, ICA internal carotid artery, M malleus, I incus, Co.

posterior semicircular canal PCOM A PCA Fig. 6 Surgical view of the anterior transpetrosal approach right side GSPN greater superficial petrosal nerve, Co.

5 18 GSPN V3 Fig. 5 GSPN ICA Co. burr 3 mm diamond burr 2 mm diamond burr drilling N Eustachian tube Tympanic cavity MMA V3 ICA M GSPN GG Co CN Tensor tympani M Bill s bar LSC SVN SSC PSC GSPN Co / Middle fossa dura SPS BA Area for drilling in anterior transpetrosal approach ICA SCA Fig. 5 Surgical anatomy of the middle cranial fossa right side The drilling area in the anterior transpetrosal approach is indicated by green. MMA middle meningeal artery, ICA internal carotid artery, M malleus, I incus, Co. cochlea, GG geniculate ganglion, CN cochlear nerve, SVN superior vestibular nerve, SPS superior petrosal sinus, SSC superior semicircular canal, LSC lateral semicircular canal, PSC posterior semicircular canal PCOM A PCA Fig. 6 Surgical view of the anterior transpetrosal approach right side GSPN greater superficial petrosal nerve, Co. cochlea, BA basilar artery, SCA superior cerebellar artery, PCA posterior cerebral artery, ICA internal carotid artery A B C D L E F G H Fig. 7 Case 1. A 38 year old woman with left trigeminal schwannoma Upper preoperative radiological findings. Contrast enhanced T1 weighted MR axial A, B and coronal C sections and a bone window temporal bone CT scan D. Lower postoperative radiological findings showing total removal of the tumor. Contrast enhanced T1 weighted MR axial E, F and coronal G sections and a bone window temporal bone CT scan H arrow drilled area and approach direction

A GSPN B C R MFD D E F T V3 MC H G I Ⅵ Ⅴ Ⅴ Fig.

dura MFD from the middle cranial fossa A and identifying the greater

was started on V3 D, and the outer wall of the Meckel s cave MC was

After opening the MC, the tumor T was totally removed F, and almost all

Finally, the intact abducens nerve VI was identified.

錐体静脈に注意しながら三叉神経根を軽 1 症例 1 Fig. 7 8 く引くと外転神経や脳底動脈が確認される Fig.

腫瘍は左 Meckel 腔にらの feeder を処理すると出血量を減らすことができ存在し小脳橋角部に進展して脳幹を圧迫しているケー 11

考えられた Fig. 7 る重要である必要箇所に骨ろうをていねいに充填し有手術所見 Fig.

6 A GSPN B C R MFD D E F T V3 MC H G I Ⅵ Ⅴ Ⅴ Fig. 8 Intraoperative photos in Case 1 After dissecting the left middle fossa dura MFD from the middle cranial fossa A and identifying the greater superficial petrosal nerve GSPN, Kawase s rhomboid R was exposed B and drilled C. Interdural dissection between the meningeal dura and the periosteal dura was started on V3 D, and the outer wall of the Meckel s cave MC was entirely exposed E. After opening the MC, the tumor T was totally removed F, and almost all the intact fibers of the trigeminal nerve V were preserved G, H. Finally, the intact abducens nerve VI was identified. があり注意を要する Meckel 腔を覆う硬膜を十分に開代表症例放し上錐体静脈洞を切断すると三叉神経根の可動性が得られる錐体静脈に注意しながら三叉神経根を軽 1 症例 1 Fig. 7 8 く引くと外転神経や脳底動脈が確認される Fig. 6 患者 38 歳女性左顔面の痛みで発症した左三叉神髄膜腫の場合滑車神経と三叉神経の間でテント動脈か経N腫に対して手術を施行した腫瘍は左 Meckel 腔にらの feeder を処理すると出血量を減らすことができ存在し小脳橋角部に進展して脳幹を圧迫しているケー 11 スで典型的な anterior transpetrosal approach の適応と硬膜内操作を終えた後の修復は最後のヤマ場として考えられた Fig. 7 る重要である必要箇所に骨ろうをていねいに充填し有手術所見 Fig. 8 左側頭開頭を行い中頭蓋窩硬膜を茎の pericranial flap を中頭蓋窩底に敷き込み側頭葉硬大錐体神経 GSPN を広く中頭蓋底より/離し A 膜と可能な限り縫合するフィブリン糊とゼルフォーム同部を削開保存して河瀬の菱形部 R を露出し B にて固定して気道内圧を上昇させて髄液の漏れがない V3 部の meningeal dura と periosteal dura のした C ことを確認する Meckel 腔の外側壁を露出した後に間で/離を行い D 切開して腫瘍 T を摘出していき F 最終的に E Jpn J Neurosurg VOL. 21 NO

7 R A B C D E F G H I J Fig. 9 Case 2. A 34 year old woman with right pontine cavernous angioma A D preoperative radiological findings. Contrast enhanced MR T1 weighted A and FLAIR axial B, coronal C, and sagittal D sections. E J postoperative radiological findings, showing total removal of the tumor. Contrast enhanced MR T1 weighted E and FLAIR axial F, coronal G, sagittal H sections, a bone window temporal bone CT scan I arrow drilled area and approach direction, and a skull X ray film J arrowheads craniotomy. G H I 2 V Fig A D anterior transpetrosal approach E H I J 1 retraction communication mastoid air cells GSPN 81 anterior transpetrosal approach disorientation disorientation retraction

8 40 50 ml CT MRI CISS thin slice CT thin slice 1 mm pneumatization 3D CT S vein of Labbe petrosal vein inferior petrosal sinus sphenopetrosal vein pterygoid plexus ABR SEP MEP Anterior transpetrosal approach cadaver dissection 1 Fukushima T ed The middle fossa approach Manual of skull base dissection. Pittsburgh, AF NeuroVideo, Inc. 1996, pp Fukushima T ed Combined petrosal approach Manual of skull base dissection. Pittsburgh, AF NeuroVideo, Inc. 1996, pp Garcia Ibanez E, Garcia Ibanez JL Middle fossa vestibular neurectomy a report of 373 cases. Otolaryngol Head Neck Surg , Hakuba A ed Anterior transpetrosal transtentorial approach. Surgical anatomy of the skull base. Tokyo, Miwa Shoten, 1996 pp House WF Surgical exposure of the internal auditory canal and its contents through the middle cranial fossa. Laryngoscope , Irving RM, Jackler R, Pitts L Hearing preservation in patients undergoing vestibular schwannoma surgery comparison of middle fossa and retrosigmoid approaches. J Neurosurg , Jackler RK Middle fossa craniotomies Atlas of neurotology and skull base surgery. St. Louis, Mosby Year Book, Inc., 1996, pp Jackler RK Middle fossa approaches to the internal auditory canal and cerebellopontine angle. Atlas of skull base surgery and neurotology. 2nd edition. New York, Thieme Medical Publishers, Inc., 2009, pp Kawase T, Shiobara R, Toya S Anterior transpetrosal transtentorial approach for sphenopetroclival meningiomas surgical method and results in 10 patients. Neurosurgery discussion , Anterior transpetrosal approach No Shinkei Geka No Shinkei Geka pp pp Nelson RA Middle fossa approach. Temporal bone surgical dissection manual. Los Angeles, House Ear Institute, 1991, pp Anterior transpetrosal approach 2008 p Sanna M, Saleh E, Russo A, Taibah A Extralabyrinthine approaches. Atlas of temporal bone and lateral skull base surgery New York, Thieme, 1995, pp Seo Y, Ito T, Sasaki T, Nakagawara J, Nakamura H Assessment of the anatomical relationship between the arcuate eminence and superior semicircular canal by computed tomography. Neurol Med Chir Tokyo discussion , Staecker H, Nadol JB, Ojeman R, Ronner S, McKenna MJ Hearing preservation in acoustic neuroma surgery middle fossa versus retrosigmoid approach. Am J Otol , Vol pp Yoshida K, Kawase T Trigeminal neurinomas extending into multiple fossae surgical methods and review of the literature. J Neurosurg , N No Shinkei Geka Jpn J Neurosurg VOL. 21 NO

9 24 Anterior transpetrosal approach pp Anterior transpetrosal approach Anterior transpetrosal approach Meckel N

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