Moving toward the petroclival region: a model for quantitative and anatomical analysis of tumor shift

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Object

The authors quantitatively assessed the effects of balloon inflation as a model of tumor compression on the brainstem, cranial nerves, and clivus by measuring the working area, angle of attack, and brain shift associated with the retrosigmoid approach.

Methods

Six silicone-injected cadaveric heads were dissected bilaterally via the retrosigmoid approach. Quantitative data were generated, including key anatomical points on the skull base and brainstem. All parameters were measured before and after inflation of a balloon catheter (inflation volume 4.8 ml, diameter 20 mm) intended to mimic tumor compression.

Results

Balloon inflation significantly shifted (p < 0.001) the brainstem and cranial nerve foramina (mean [± standard deviation] displacement of upper brainstem, 10.2 ± 3.7 mm; trigeminal nerve exit, 6.99 ± 2.38 mm; facial nerve exit, 9.52 ± 4.13 mm; and lower brainstem, 13.63 ± 8.45 mm). The area of exposure at the petroclivus was significantly greater with balloon inflation than without (change, 316.26 ± 166.75 mm2; p < 0.0001). Before and after balloon inflation, there was no significant difference in the angles of attack at the origin of the trigeminal nerve (p > 0.5).

Conclusions

This study adds an experimental component to the emerging field of quantitative neurosurgical anatomy. Balloon inflation can be used to model the effects of a mass lesion. The tumor simulation created “natural” retraction and an opening toward the upper clivus. The findings may be helpful in selecting a surgical approach to increase the working space for resection of certain extraaxial tumors.

Abbreviation used in this study:CPA = cerebellopontine angle.

Article Information

Address correspondence to: Joseph M. Zabramski, M.D., c/o Neuroscience Publications, Barrow Neurological Institute, 350 West Thomas Road, Phoenix, Arizona 85013. email: neuropub@chw.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Photographs depicting balloon inflation in the petroclival region and CPA. A: The middle and upper neuro-vascular complex before insertion of the balloon catheter. B: The location of the abducens nerve (VI). C: The balloon catheter has been inserted. The black mark where the balloon attaches to the catheter is positioned at the level of the seventh and eighth cranial nerve complex. The balloon is inserted behind and at the level of the trigeminal nerve. D: Injection of dye to improve visualization of the balloon. E: Inflation of the balloon. F: Partial deflation of the balloon. G: Complete deflation of the balloon. AICA = anterior inferior cerebellar artery; CER = cerebellum; SPV = superior petrosal vein; V = fifth cranial nerve; VII = seventh and eighth cranial nerve complex.

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    Upper: Bar graph demonstrating brainstem and cranial nerve displacement. Balloon inflation produced a significant shift (asterisks) of the upper and lower brainstem and the origins of the trigeminal and facial nerves. Lower: Bar graph revealing changes in the accessibility of the upper and lower clivus and the accessory nerve entry zone but no significant change in the access to the cranial nerve foramina. Asterisks represent statistically significant changes, p < 0.05. All error bars represent standard deviations.

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    Magnetic resonance images. A and B: Contrast-enhanced T1-weighted images obtained in a 59-year-old woman with a left-sided petroclival meningioma, demonstrating infratentorial brainstem compression (A) as well as supratentorial displacement of the upper pons and midbrain (B). The patient was treated via a simple retrosigmoid approach followed by an orbitozygomatic approach and Gamma Knife surgery for the residual tumor. Arrows indicate tumor compression and displacement of the brainstem. C and D: Axial T1-weighted images obtained in the cadaveric head of a 62-year-old man, revealing balloon inflation on the right side to simulate the effects of a petroclival tumor. As in the clinical case, the lower portion of the balloon (tumor) compresses the pons (arrowheads in C) and opens a corridor toward the upper clivus (compare with panel A), whereas the upper portion of the balloon extends supratentorially (D) and displaces the upper brainstem (compare with panel B).

  • View in gallery

    Bar graphs depicting the working area for the brainstem (upper) and petroclival surface (lower) with and without balloon inflation. With balloon inflation, there was a significant increase in the area of exposure of the middle and lower brainstem but not in that of the upper brainstem. With balloon inflation, there was a significant increase in the total area of exposure of the clivus. Asterisks represent a statistically significant increase, p < 0.05.

  • View in gallery

    Photographs showing the posterior fossa anatomy. A: Note the relationship of the cerebellum and the various cranial nerves. B: The balloon catheter was inserted with microscopic visualization. C and D: Partial (C) and maximal (D) inflation of the balloon. Note the gradual displacement of brainstem and soft tissue and the stretching of the cranial nerves. IX, X, XI = lower cranial nerve complex.

  • View in gallery

    Bar graphs revealing angles of approach and angular differences with and without balloon inflation. A: Vertical angle of approach to five representative posterior fossa structures without and with balloon inflation. B: The differences in the vertical angle of approach are clearer once they are plotted. C: The horizontal angle of approach with and without balloon inflation. D: Calculated differences in the horizontal angle of approach. Asterisks represent a statistically significant angular difference, p < 0.05.

References

  • 1

    Abdel Aziz KMSanan Avan Loveren HRTew JMKeller JTPensak ML: Petroclival meningiomas: predictive parameters for transpetrosal approaches. Neurosurgery 47:1391522000

    • Search Google Scholar
    • Export Citation
  • 2

    Al Mefty OFox JLSmith RR: Petrosal approach for petroclival meningiomas. Neurosurgery 22:5105171988

  • 3

    Baldwin HZMiller CGvan Loveren HRKeller JTDaspit CPSpetzler RF: The far lateral/combined supra- and infratentorial approach. A human cadaveric prosection model for routes of access to the petroclival region and ventral brain stem. J Neurosurg 81:60681994

    • Search Google Scholar
    • Export Citation
  • 4

    Baldwin HZSpetzler RFWascher TMDaspit CP: The far lateral-combined supra- and infratentorial approach: clinical experience. Acta Neurochir (Wien) 134:1551581995

    • Search Google Scholar
    • Export Citation
  • 5

    Bambakidis NCGonzalez LFAmin-Hanjani SDeshmukh VRPorter RWDaspit PC: Combined skull base approaches to the posterior fossa. Technical note. Neurosurg Focus 19:2E82005

    • Search Google Scholar
    • Export Citation
  • 6

    Bricolo APTurazzi STalacchi ACristofori L: Microsurgical removal of petroclival meningiomas: a report of 33 patients. Neurosurgery 31:8138281992

    • Search Google Scholar
    • Export Citation
  • 7

    Carvalho GAMatthies CTatagiba MEghbal RSamii M: Impact of computed tomographic and magnetic resonance imaging findings on surgical outcome in petroclival meningiomas. Neurosurgery 47:128712952000

    • Search Google Scholar
    • Export Citation
  • 8

    Chanda ANanda A: Partial labyrinthectomy petrous apicectomy approach to the petroclival region: an anatomic and technical study. Neurosurgery 51:1471602002

    • Search Google Scholar
    • Export Citation
  • 9

    Cho CWAl Mefty O: Combined petrosal approach to petroclival meningiomas. Neurosurgery 51:7087182002

  • 10

    Couldwell WTFukushima TGiannotta SLWeiss MH: Petroclival meningiomas: surgical experience in 109 cases. J Neurosurg 84:20281996

    • Search Google Scholar
    • Export Citation
  • 11

    de Oliveira ERhoton AL JrPeace D: Microsurgical anatomy of the region of the foramen magnum. Surg Neurol 24:2933521985

  • 12

    Deshmukh VRFigueiredo EGDeshmukh PCrawford NRPreul MCSpetzler RF: Quantification and comparison of telovelar and transvermian approaches to the fourth ventricle. Neurosurgery 58:2 SupplONS-202ONS-2072006

    • Search Google Scholar
    • Export Citation
  • 13

    Figueiredo EGDeshmukh PZabramski JMPreul MCCrawford NRSiwanuwatn R: Quantitative anatomic study of three surgical approaches to the anterior communicating artery complex. Neurosurgery 56:2 Suppl3974052005

    • Search Google Scholar
    • Export Citation
  • 14

    Figueiredo EGZabramski JMDeshmukh PCrawford NRPreul MCSpetzler RF: Anatomical and quantitative description of the transcavernous approach to interpeduncular and prepontine cisterns. Technical note. J Neurosurg 104:9579642006

    • Search Google Scholar
    • Export Citation
  • 15

    Goel AMuzumdar D: Conventional posterior fossa approach for surgery on petroclival meningiomas: a report on an experience with 28 cases. Surg Neurol 62:3323402004

    • Search Google Scholar
    • Export Citation
  • 16

    Gonzalez LFCrawford NRHorgan MADeshmukh PZabramski JMSpetzler RF: Working area and angle of attack in three cranial base approaches: pterional, orbitozygomatic, and maxillary extension of the orbitozygomatic approach. Neurosurgery 50:5505572002

    • Search Google Scholar
    • Export Citation
  • 17

    Hakuba ANishimura SJang BJ: A combined retroauricular and preauricular transpetrosal-transtentorial approach to clivus meningiomas. Surg Neurol 30:1081161988

    • Search Google Scholar
    • Export Citation
  • 18

    Horgan MAAnderson GJKellogg JXSchwartz MSSpektor SMcMenomey SO: Classification and quantification of the petrosal approach to the petroclival region. J Neurosurg 93:1081122000

    • Search Google Scholar
    • Export Citation
  • 19

    Horgan MADelashaw JBSchwartz MSKellogg JXSpektor SMcMenomey SO: Transcrusal approach to the petroclival region with hearing preservation. Technical note and illustrative cases. J Neurosurg 94:6606662001

    • Search Google Scholar
    • Export Citation
  • 20

    House WFDe la Cruz AHitselberger WE: Surgery of the skull base: transcochlear approach to the petrous apex and clivus. Otolaryngology 86:ORL-770ORL-7791978

    • Search Google Scholar
    • Export Citation
  • 21

    Kawase TShiobara RToya S: Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients. Neurosurgery 28:8698761991

    • Search Google Scholar
    • Export Citation
  • 22

    Kawashima MTanriover NRhoton ALUlm AJMatsushima T: Comparison of the far lateral and extreme lateral variants of the atlanto-occipital transarticular approach to anterior extradural lesions of the craniovertebral junction. Neurosurgery 53:6626752003

    • Search Google Scholar
    • Export Citation
  • 23

    Little KMFriedman AHSampson JHWanibuchi MFukushima T: Surgical management of petroclival meningiomas: defining resection goals based on risk of neurological morbidity and tumor recurrence rates in 137 patients. Neurosurgery 56:5465592005

    • Search Google Scholar
    • Export Citation
  • 24

    Matsuno HRhoton ALPeace D: Microsurgical anatomy of the posterior fossa cisterns. Neurosurgery 23:58801988

  • 25

    Matsushima TRhoton ALde Oliveira EPeace D: Microsurgical anatomy of the veins of the posterior fossa. J Neurosurg 59:631051983

    • Search Google Scholar
    • Export Citation
  • 26

    Rhoton AL: The cerebellar arteries. Neurosurgery 47:3 SupplS29S682000

  • 27

    Rhoton AL: The cerebellopontine angle and posterior fossa cranial nerves by the retrosigmoid approach. Neurosurgery 47:3 SupplS93S1292000

    • Search Google Scholar
    • Export Citation
  • 28

    Rhoton AL: Microsurgical anatomy and neurosurgical pathology. Clin Neurosurg 51:11252004

  • 29

    Rhoton AL: Microsurgical anatomy of acoustic neuromas. Neurol Res 6:3211984

  • 30

    Rhoton AL: Suboccipital–retrolabyrinthine removal of acoustic neuromas. J Fla Med Assoc 70:8959011983

  • 31

    Rhoton AL: The three neurovascular complexes in the posterior fossa and vascular compression syndromes (honored guest lecture). Clin Neurosurg 41:1121491994

    • Search Google Scholar
    • Export Citation
  • 32

    Roberti FSekhar LNKalavakonda CWright DC: Posterior fossa meningiomas: surgical experience in 161 cases. Surg Neurol 56:8212001

    • Search Google Scholar
    • Export Citation
  • 33

    Rubino PARhoton ALTong XOliveira E: Three-dimensional relationships of the optic radiation. Neurosurgery 57:4 Suppl2192272005

    • Search Google Scholar
    • Export Citation
  • 34

    Samii MAmmirati M: The combined supra-infratentorial pre-sigmoid sinus avenue to the petroclival region. Surgical technique and clinical applications. Acta Neurochir (Wien) 95:6121988

    • Search Google Scholar
    • Export Citation
  • 35

    Samii MAmmirati MMahran ABini WSepehrnia A: Surgery of petroclival meningiomas: report of 24 cases. Neurosurgery 24:12171989

    • Search Google Scholar
    • Export Citation
  • 36

    Samii MTatagiba M: Experience with 36 surgical cases of petroclival meningiomas. Acta Neurochir (Wien) 118:27321992

  • 37

    Samii MTatagiba MCarvalho GA: Resection of large petroclival meningiomas by the simple retrosigmoid route. J Clin Neurosci 6:27301999

    • Search Google Scholar
    • Export Citation
  • 38

    Samii MTatagiba MCarvalho GA: Retrosigmoid intradural suprameatal approach to Meckel's cave and the middle fossa: surgical technique and outcome. J Neurosurg 92:2352412000

    • Search Google Scholar
    • Export Citation
  • 39

    Sekhar LNJannetta PJ: Cerebellopontine angle meningiomas. Microsurgical excision and follow-up results. J Neurosurg 60:5005051984

    • Search Google Scholar
    • Export Citation
  • 40

    Sekhar LNJannetta PJBurkhart LEJanosky JE: Meningiomas involving the clivus: a six-year experience with 41 patients. Neurosurgery 27:7647811990

    • Search Google Scholar
    • Export Citation
  • 41

    Sekhar LNSchessel DABucur SDRaso JLWright DC: Partial labyrinthectomy petrous apicectomy approach to neoplastic and vascular lesions of the petroclival area. Neurosurgery 44:5375521999

    • Search Google Scholar
    • Export Citation
  • 42

    Seoane ERhoton AL: Suprameatal extension of the retrosigmoid approach: microsurgical anatomy. Neurosurgery 44:5535601999

  • 43

    Siwanuwatn RDeshmukh PFigueiredo EGCrawford NRSpetzler RFPreul 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 104:1371422006

    • Search Google Scholar
    • Export Citation
  • 44

    Spallone AMakhmudov UBMukhamedjanov DJTcherekajev VA: Petroclival meningioma. An attempt to define the role of skull base approaches in their surgical management. Surg Neurol 51:4124201999

    • Search Google Scholar
    • Export Citation
  • 45

    Spektor SAnderson GJMcMenomey SOHorgan MAKellogg JXDelashaw JB: Quantitative description of the far-lateral trans-condylar transtubercular approach to the foramen magnum and clivus. J Neurosurg 92:8248312000

    • Search Google Scholar
    • Export Citation
  • 46

    Spetzler RFDaspit CPPappas CT: The combined supra- and infratentorial approach for lesions of the petrous and clival regions: experience with 46 cases. J Neurosurg 76:5885991992

    • Search Google Scholar
    • Export Citation
  • 47

    Spetzler RFHamilton MGDaspit CP: Petroclival lesions. Clin Neurosurg 41:62821994

  • 48

    Suhardja AAgur AMCusimano MD: Anatomical basis of approaches to foramen magnum and lower clival meningiomas: comparison of retrosigmoid and transcondylar approaches. Neurosurg Focus 14:6E92003

    • Search Google Scholar
    • Export Citation
  • 49

    Tanriover NUlm AJRhoton AL JrKawashima MYoshioka NLewis SB: One-piece versus two-piece orbitozygomatic craniotomy: quantitative and qualitative considerations. Neurosurgery 58:2 SupplONS-229ONS-2372006

    • Search Google Scholar
    • Export Citation
  • 50

    Tedeschi HRhoton AL: Lateral approaches to the petroclival region. Surg Neurol 41:1802161994

  • 51

    Van Havenbergh TCarvalho GTatagiba MPlets CSamii M: Natural history of petroclival meningiomas. Neurosurgery 52:55642003

  • 52

    Yaşargil MGMortara RWCurcic M: Meningiomas of basal posterior cranial fossa. Adv Techn Stand Neurosurg 7:31181980

  • 53

    Zentner JMeyer BVieweg UHerberhold CSchramm J: Petroclival meningiomas: is radical resection always the best option?. J Neurol Neurosurg Psychiatry 62:3413451997

    • Search Google Scholar
    • Export Citation

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