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  • Posterior Cavernous Anterior Transpetrosal Posteromedial Rhomboid (Dolenc-Kawase Rhomboid) Approach to Posterior Cavernous and Petroclival Lesions

    Final Number:
    654

    Authors:
    Ashish Suri; Manjul Tripathi; Rama C. Deo; Vinkle Srivastav; Britty Baby; Tara S. Roy; Sanjeev Lalwani; Subodh Kumar; Prem Kalra; Subhashish Banerji; Sanjiva Prasad

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2014 Annual Meeting

    Introduction: Traditional Kawase’s approach(Arcuate eminence(AE),GSPN,Petrous ridge(PR)) provides 10x5mm fenestration at petrous apex between Vnv. and internal auditory canal. Despite permitting key access,exposure is conical and crowded; it does not allow proper exposure to the Vnv exiting from tentorium, VIth nerve in Dorello canal and posterior clinoid process. Modified technique of additional trans-cavernous exploration and medial mobilization of Vnv. results in posterior cavernous anterior transpetrosal posteromedial Modified Dolenc-Kawase(MDK)-rhomboid approach.

    Methods: Dissection of posterior cavernous sinus wall over the V1,V2,V3 and Gasserian Ganglion(GG) permits access to MDK-rhomboid(AE-posterior,GSPN-lateral,PR-medial and V3+GG-anterior). Ligation and division of superior petrosal sinus at posterior clinoid process and elevation+mobilization of Vnv. permits enlarged view of previous inaccessible areas. Spectrum of patients with posterior cavernous+petroclival lesions were treated with this approach. Volumetric analysis of temporal bones with 3D laser scanning of dry and drilled bones for respective triangles and rhomboid areas; comparing difference of exposure with traditional versus modified approaches on cadaver dissection were analyzed for evaluation of area exposed, surgical freedom and angulation of approach.

    Results: MDK rhomboid provides 1.5X larger area and 2.0X greater volume of bone at anterior petrous apex in comparison to Kawase’s triangle. Cadaver dissection objectified technical feasibility of MDK approach providing nearly 1.5 to 2 times larger fenestration with improved view and angulation to posterior cranial fossa. MDK rhomboid approach was used in the treatment of petroclival meningiomas(35),giant dumbell trigeminal schwannoma(11),clival chordoma(6),clival chondrosarcoma(4),trochlear schwanomma(1),giant posterior fossa craniophrangioma(6), middle+posterior fossa epidermoid(4),hypothalamic hamartoma(1),giant low basilar bifurcation aneurysm(2),petroclival hemangiopericytoma(1) and histiocytosis(Rosai Dorfman).

    Conclusions: MDK rhomboid approach is technically demanding and requires thorough knowledge of anatomy and pathology; it provides safe corridor during the microsurgical treatment of spectrum of skull base lesions. The larger fenestration at petrous apex provides greater surgical freedom at Dorello’s canal, Gasserian ganglion and prepontine area and better anteroposterior angulation in comparison to traditional Kawase’s approach.

    Patient Care: Posterior cavernous anterior transpetrosal posteromedial Modified Dolenc-Kawase(MDK)-rhomboid approach is a safe approach for treatment of wide spectrum of central and posterior fossa lesions.

    Learning Objectives: 1. Posterior cavernous anterior transpetrosal posteromedial Modified Dolenc-Kawase(MDK)-rhomboid approach is technically demanding and requires thorough knowledge of anatomy and pathology. 2. MDK Rhomboid approach provides safe corridor during the microsurgical treatment of spectrum of skull base lesions. 3. The larger fenestration at petrous apex provides greater surgical freedom at Dorello’s canal, Gasserian ganglion and prepontine area and better anteroposterior angulation in comparison to traditional Kawase’s approach.

    References: 1. Al-Mefty O, Anand VK: Zygomatic approach to skull-base lesions. J Neurosurg 73:668–673, 1990. 2. Al-Mefty O, Ayoubi S, Smith RR: The petrosal approach: Indications, technique, and results. Acta Neurochir Suppl(Wien) 53:166–170, 1991.. 3. Bambakidis NC, Kakarla UK, Kim LJ, Nakaji P, Porter RW, Daspit CP, Spetzler RF. Evolution of surgical approaches in the treatment of petroclival meningiomas: a retrospective review. Neurosurgery 62:1182-1191, 2008. 4. Bernardo A, Kim HK, Zabramski JM, Passacantilli E, Deshmukh P, Spetzler RF. A Functional Sparing "Conservative" Perilabyrinthine-Transpetrosal Approach to the Anterior Brain Stem and Clivus. AANS http://www.aans.org/Media/Article.aspx?ArticleID=17821 (Accessed Dec 26, 2013) 5. Bochenek Z, Kukwa A: An extended approach through the middle cranial fossa to the internal auditory meatus and the cerebellopontine angle. Acta Otolaryngol (Stockh) 80:410–414, 1975. 6. Chang SW, Wu A, Gore P, Beres E, Porter RW, Preul MC, Spetzler RF, Bambakidis NC. Quantitative Comparison of Kawase’s Approach versus The Retrosigmoid Approach: Implications for Tumors Involving Both Middle and Posterior Fossae. Neurosurgery64: 44-52; 2009. 7. Day JD, Fukushima T, Giannotta S. Microanatomical Study of the Extradural Middle Fossa Approach to the Petroclival and Posterior Cavernous Sinus Region: Description of the Rhomboid Construct. Neurosurgery34: 1009-1016; 1994. 8. Dolenc VV: Frontotemporal epidural approach to trigeminal neuromas. Acta Neurochir (Wien) 130:55–65, 1994. 9. Gupta SK, Salunke P. Intradural anterior petrosectomy for petroclival meningiomas: a new surgical technique and results in 5 patients. J Neurosurg 117:1007–1012, 2012. 10. Hakuba A, Nishimura S, Jang BJ: A combined retroauricular and preauricular transpetrosal-transtentorial approach to clivus meningiomas. Surg Neurol 30:108–116, 1988. 11. Harsh GR, Sekhar LN: The subtemporal, transcavernous, anterior transpetrosal approach to the upper brain stem and clivus. J Neurosurg 77:709–717, 1992. 12. Horgan MA, Anderson GJ, Kellogg JX, Schwartz MS, Spektor S, McMenomey SO, Delashaw JB. Classification and quantification of the petrosal approach to the petroclival region. J Neurosurg 93:108-112,2000. 13. House WF, Hitselberger WE, Horn KL: The middle fossa transpetrous approach to the anterior-superior cerebellopontine angle. Am J Otol 7:1–4, 1986. 14. Kawase T, Shiobara R, Shiego T. Anterior Transpetrosal-Transtentorial Approach for Sphenopetroclival Meningiomas: Surgical Method and Results in 10 patients. Neurosurgery 28:869-876; 1991. 15. Kawase T, Toya S, Shiobara R, Mine T: Transpetrosal approach for aneurysms of the lower basilar artery. J Neurosurg 63:857–861, 1985. 16. Martin RG, Grant JL, Peace D, Theiss C, Rhoton AL Jr. Microsurgical relationships of the anterior inferior cerebellar artery and the facial-vestibulocochlear nerve complex. Neurosurgery 6:483-507, 1980. 17. Sakata S. microsurgical Anatomy of the Basilar Artery: Surgical Approaches to the Basilar Trunk and Vertebrobasilar Junction Aneurysms. Kor J Cerebrovascular Disease 3:5-10, 2001. 18. Samii M, Ammirati M: The combined supra-infratentorial presigmoid sinus avenue to the petro-clival region. Surgical technique and clinical applications. Acta Neurochir 95:6–12, 1988. 19. Sincoff EH, Delashaw JB. Petroclival surgery. J Neurosurg 104:4-5, 2006. 20. Siwanuwatn R, Deshmukh P, Figueiredo EG, Crawford NR, Spetzler RF, Preul MC. Quantitative analysis of the working area and angle of attack for the retrosigmoid, combined petrosal and transcochlear approaches to the petroclival region. J Neurosurg 104:137-142, 2006. 21. Sugita K, Kobayashi S, Takemae T, Tada T, Tanaka Y. Aneurysms of the basilar artery trunk. J Neurosurg 66:500-5, 1987.

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