Endoscopic endonasal approach to Meckel’s cave

Zoli et al. published all patients with Meckel’s cave tumors treated at Bologna by endoscopic endonasal approach (EEA) between 2002 and 2016. Patients underwent brain MRICT angiography, and neurological evaluation before surgery. Complications were considered based on the surgical records. All examinations were repeated after 3 and 12 months, then annually. The median follow-up was of 44.1 months (range 16-210).

The series included 8 patients (4 F): 5 neuromas, 1 meningioma, 1 chondrosarcoma, and 1 epidermoid cyst. The median age at treatment was 54.5 years (range 21-70). Three tumors presented with a posterior fossa extension. Radical removal of the MC portion of the tumor was achieved in 7 out of 8 cases. Two patients developed a permanent and transitory deficit of the sixth cranial nerve, respectively. No tumor recurrence was observed at follow-up.

In this preliminary series, the EEA appeared an effective and safe approach to MC tumors. The technique could be advantageous to treat tumors located in the antero-medial aspects of MC displacing the trigeminal structures posteriorly and laterally. A favorable index of an adequate working space for this approach is represented by the ICA medialization, while tumor extension to the posterior fossa represents the main limitation to radical removal of this route 1).

The EE transmaxillary transinferior orbital fissure approach was simulated in 10 specimens. The approach included an ethmoidectomy followed by an extended medial maxillectomy with transposition of the nasolacrimal duct. The infraorbital fissure was opened, and the infraorbital neurovascular bundle was transposed inferiorly. A quadrilateral space, bound by the maxillary nerve inferomedially, ophthalmic nerve superomedially, infraorbital nerve inferolaterally, and floor of the orbit superolaterally, was exposed. The distances from the foramen rotundum (FR) to the ICA, orbital apex (OA), and infratemporal crest (ITC) and from the OA to the ICA and ITC were measured.

The distances obtained were FR-ICA = 19.42 ± 2.03 mm, FR-ITC = 18.76 ± 1.75 mm, FR-OA = 8.54 ± 1.34 mm, OA-ITC = 19.78 ± 2.63 mm, and OA-ICA = 20.64 ± 142 mm. Two imaginary lines defining safety boundaries were observed between the paraclival ICA and OA, and between the OA and ITC (safety lines 1 and 2).

The reported approach provides a less invasive route compared to contemporary approaches, allowing expanded views and manipulation anteromedial and anterolateral to MC. It may be safer than the existing approaches as it does not require transposition of the ICA, infratemporal fossa, and pterygopalatine fossa, and allows access to tumors located anteriorly on the floor of the middle cranial fossa 2).

Many benign and malignant tumors as well as other inflammatory or vascular diseases may be located in the areas of Meckel’s cave or the cavernous sinus. Except for typical features such as for meningiomas, imaging may not by itself be sufficient to choose the best therapeutic option. Thus, even though modern therapy (chemotherapy, radiotherapy, or radiosurgery) dramatically reduces the field of surgery in this challenging location, there is still some place for surgical biopsy or tumor removal in selected cases. Until recently, the microscopic subtemporal extradural approach with or without orbitozygomatic removal was classically used to approach Meckel’s cave but with a non-negligible morbidity. Percutaneous biopsy using the Hartel technique has been developed for biopsy of such tumors but may fail in the case of firm tumors, and additionally it is not appropriate for anterior parasellar tumors. With the development of endoscopy, the endonasal route now represents an interesting alternative approach to Meckel’s cave as well as the cavernous sinus.

Jouanneau et al. from the Pierre Wertheimer Hospital, described the modus operandi and discuss what should be the appropriate indication of the use of the endonasal endoscopic approach for Meckel’s cave disease in the armamentarium of the skull base surgeon 3).

Van Rompaey et al performed an endoscopic endonasal approach as well as a lateral approach to the Meckel cave on six anatomic specimens. To access the Meckel cave endoscopically, a complete sphenoethmoidectomy and maxillary antrostomy followed by a transpterygoid approach was performed. For lateral access, a pterional craniotomy with extradural dissection was performed.

The endoscopic endonasal approach allowed adequate access to the Gasserian ganglion. All the relevant anatomy was identified without difficulty. Both approaches allowed for a similar exposure, but the endonasal approach avoided brain retraction and improved anteromedial exposure of the Gasserian ganglion. The lateral approach provided improved access posterolaterally and to the superior portion.

The endoscopic endonasal approach to the Meckel cave is anatomically feasible. The morbidity associated with brain retraction from the open approaches can be avoided. Further understanding of the endoscopic anatomy within this region can facilitate continued advancement in endoscopic endonasal surgery and improvement in the safety and efficacy of these procedures 4).

The opening of Meckel’s Cave may be particularly useful for lesions located in the cerebellopontine angle having a minor component that extends anteriorly and laterally in the middle cranial fossa 5).1) Zoli M, Ratti S, Guaraldi F, Milanese L, Pasquini E, Frank G, Billi AM, Manzoli L, Cocco L, Mazzatenta D. Endoscopic endonasal approach to primitive Meckel’s cave tumors: a clinical series. Acta Neurochir (Wien). 2018 Dec;160(12):2349-2361. doi: 10.1007/s00701-018-3708-4. Epub 2018 Oct 31. PubMed PMID: 30382359.2) Zhang X, Tabani H, El-Sayed I, Russell M, Feng X, Benet A. The Endoscopic Endonasal Transmaxillary Approach to Meckel’s Cave Through the Inferior Orbital Fissure. Oper Neurosurg (Hagerstown). 2017 Jun 1;13(3):367-373. doi: 10.1093/ons/opx009. PubMed PMID: 28521351.3) Jouanneau E, Simon E, Jacquesson T, Sindou M, Tringali S, Messerer M, Berhouma M. The endoscopic endonasal approach to the Meckel’s cave tumors: surgical technique and indications. World Neurosurg. 2014 Dec;82(6 Suppl):S155-61. doi: 10.1016/j.wneu.2014.08.003. Epub 2014 Aug 12. Review. PubMed PMID: 25107326.4) Van Rompaey J, Bush C, Khabbaz E, Vender J, Panizza B, Solares CA. What is the Best Route to the Meckel Cave? Anatomical Comparison between the Endoscopic Endonasal Approach and a Lateral Approach. J Neurol Surg B Skull Base. 2013 Dec;74(6):331-6. doi: 10.1055/s-0033-1342989. Epub 2013 Apr 5. PubMed PMID: 24436933.5) Acerbi F, Broggi M, Gaini SM, Tschabitscher M. Microsurgical endoscopic-assisted retrosigmoid intradural suprameatal approach: anatomical considerations. J Neurosurg Sci. 2010 Jun;54(2):55-63. PubMed PMID: 21313956.

International 36th Course for Percutaneous Endoscopic Spinal Surgery and Complementary Minimal Invasive Techniques of the International Society for Minimal Intervention in Spinal Surgery: ISMISS

September 7 — September 8

Homburg Saar, Germany

More Information: http://www.ismiss.com/4-0-meetings.html

Endoscopic and Keyhole Cranial Base Surgery

Endoscopic and Keyhole Cranial Base Surgery

by James J. Evans and Tyler J. Kenning

 List Price:  $236.69
The first two sections of this text address endoscopic and keyhole surgical procedures for cranial base and deep brain structures.  These sections provide a comprehensive, state-of-the art review of this minimally invasive field and will serve as a valuable resource for clinicians, surgeons and researchers with an interest in cranial base surgery.  The philosophy, techniques, indications and limitations of endoscopic and keyhole cranial base surgery are covered in detail. This reference includes a discussion of the basic principles of these approaches as well as the preoperative planning, intraoperative pearls, and reconstruction techniques.  The thorough descriptions of the practical and technical aspects are accompanied by extensive illustrations, figures and operative images.
Extending beyond the technical details of these procedures, this text provides a third section that focuses on a thorough analysis and comparison of the endoscopic, keyhole and traditional open approaches to specific intracranial regions.  Utilizing a “target-based” approach, the utility of each surgical technique is evaluated in regard to accessing pathology of the anterior, middle and posterior fossa cranial base as well as the deep central regions of the brain. All chapters are written by experts in their fields and include the most up to date scientific and clinical information.
 Endoscopic and Keyhole Cranial Base Surgery will be a valuable resource to specialists in optimizing surgical results and improving patient outcomes.


The Pittsburgh Course: Comprehensive Endoscopic Endonasal Surgery of the Skull Base

The Pittsburgh Course: Comprehensive Endoscopic Endonasal Surgery of the Skull Base

November 8 — November 11

Pittsburgh, PA, USA

Atlas of Endoscopic Neurosurgery of the Third Ventricle: Basic Principles for Ventricular Approaches and Essential Intraoperative Anatomy

Atlas of Endoscopic Neurosurgery of the Third Ventricle: Basic Principles for Ventricular Approaches and Essential Intraoperative Anatomy

Atlas of Endoscopic Neurosurgery of the Third Ventricle: Basic Principles for Ventricular Approaches and Essential Intraoperative Anatomy

By Roberto Alexandre Dezena

List Price: $199.00
This book describes in practical terms the endoscopic neurosurgery of the third ventricle and surrounding structures, emphasizing aspects of intraoperative endoscopic anatomy and ventricular approaches for main diseases, complemented by CT / MRI images. It is divided in two parts: Part I describes the evolution of the description of the ventricular system and traditional ventricular anatomy, besides the endoscopic neurosurgery evolution and current concepts, with images and schematic drawings, while Part II presents a collection of intraoperative images of endoscopic procedures, focusing in anatomy and main pathologies, complemented by schemes of the surgical approaches and CT / MRI images.
The Atlas of Endoscopic Neurosurgery of the Third Ventricle offers a revealing guide to the subject, addressing the needs of medical students, neuroscientists, neurologists and especially neurosurgeons.

Product Details

  • Original language: English
  • Number of items: 1
  • Dimensions: 11.41″ h x .88″ w x 8.51″ l,
  • Binding: Hardcover
  • 271 pages

About the Author

Roberto Alexandre Dezena: MD from the Federal University of Triângulo Mineiro, Uberaba, Brazil (2003), completed his residency training in Neurosurgery at Santa Casa de Misericórdia de Ribeirão Preto, Brazil (2009), achieved his PhD in Neurosurgery at Ribeirão Preto Medical School of University of São Paulo, Brazil (2011), and his Postdoctoral Fellowship at Federal University of Triângulo Mineiro, Uberaba, Brazil (2014). In Brazil, is Full Member of Brazilian Society of Neurosurgery (SBN) and Brazilian Academy of Neurosurgery (ABNc). Internationally, is Fellow of World Federation of Neurosurgical Societes (WFNS), Active Member of both International Society for Pediatric Neurosurgery (ISPN) and International Federation of Neuroendoscopy (IFNE), and Full Member of both Latin American Federation of Neurosurgery Societes (FLANC) and Latin American Group of Studies in Neuroendoscopy (GLEN). Fellow of University of Tübingen, Germany, and University of Hiroshima, Japan. Currently is Chief of Division of Neurosurgery at Clinics Hospital, Neurosurgery Residency Director, and Professor of Postgraduate Program in Health Sciences and Postgraduate Program in Applied Biosciences, all in Federal University of Triângulo Mineiro, Uberaba, Brazil. Main neurosurgical areas in vascular and neuro-oncology microneurosurgery, endoscopic neurosurgery, pediatric neurosurgery, spinal surgery and neurotrauma. Main research areas in endoscopic neurosurgery, pediatric neurosurgery, neurotrauma, experimental cerebral ischemia and basic neurosciences. Editorial Board Member of International Journal of Anesthesiology Research (Phaps), Journal of Neurology and Stroke (Medcrave), EC Neurology (EC), and International Journal of Pediatrics and Children Health (Savvy). Reviewer of several online international scientific journals, highlighting World Neurosurgery (WFNS), Neurological Research (Maney) and Journal of Neurosurgical Sciences (Minerva).

International Summer School: Transnasal Endoscopic Surgery: From Sinuses to Skull Base

International Summer School: Transnasal Endoscopic Surgery: From Sinuses to Skull Base

July 3 — July 7

Brescia, Italy

4th Endoscopic Skull Base Masterclass & Mini Symposium

4th Endoscopic Skull Base Masterclass & Mini Symposium

June 28 — June 30

Leiden, Netherlands
CME course and mini-Symposium: Treatment of skull base meningioma: surgical strategy, approaches and outcomes.
Course flyer.
More information available at: http://www.skullbasecourse.nl/

Microscopic and Endoscopic Approaches to the Skull Base

Microscopic and Endoscopic Approaches to the Skull Base

June 7 — June 9

Strasbourg, France
Taking place at IRCAD in Strasbourg – http://www.ircad.fr/ 
Course directors:
Prof. Froelich – Lariboisière Hospital Paris and Prof. Debry – University Hospital of Strasbourg.
Course flyer.
Registration:  http://www.ircad.fr/training-center/course-calendar/?type=advanced&spec=neuro
Course description:
This workshop is intended for neurosurgeons or ENTs from the world over, to learn and practice the technical skills required for skull base surgery. It has been structured to provide both didactic lectures and intensive hands-on cadaver dissection sessions, covering a broad spectrum of transcranial and endoscopic approaches. A panel of distinguished leaders in these fields will deliver lectures focusing on skull base anatomy, transcranial and endoscopic approaches as well as therapeutic strategies for skull base lesions. The scientific program will include a guest speaker session on a topic related to skull base neurosurgery, with lectures given by world-renowned experts. Topics previously discussed included acoustic neuroma, microvascular decompression, radiosurgery for skull base lesions, pediatric skull base neurosurgery and revascularization techniques. Attendees will benefit from the outstanding surgical lab environment of the IRCAD with state-of-the-art equipment provided by our dedicated sponsors. For hands-on sessions, a demonstration will be performed at the master station, transmitted onto a screen at each workstation. In the meantime, participants will work as a team of two on prepared injected fixed specimens under the guidance of a distinguished expert Faculty.  

Target audience:
Practicing neurosurgeons and ENT specialists, fellows and residents in training 

Course objectives:
– To provide an overview of the complex anatomy of the skull base
–  To cover a broad spectrum of the skull base approaches and describe the technical steps of each specific approach
– To discuss indications of skull base approaches and surgical strategies
– To provide hands-on sessions on cadaveric specimens and improve skills
– To become more familiar with endoscopic endonasal approaches
– To understand the rationale and challenge of endoscopic endonasal approaches to the skull base
– To allow case discussions between experts and trainees Educational methods
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