Endoscopic extradural supraorbital approach to the temporal pole and adjacent area: technical note

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The authors’ initial experience with the endoscopic extradural supraorbital approach to the temporal pole and adjacent area is reported. Fully endoscopic surgery using the extradural space via a supraorbital keyhole was performed for tumors in or around the temporal pole, including temporal pole cavernous angioma, sphenoid ridge meningioma, and cavernous sinus pituitary adenoma, mainly using 4-mm, 0° and 30° endoscopes and single-shaft instruments. After making a supraorbital keyhole, a 4-mm, 30° endoscope was advanced into the extradural space of the anterior cranial fossa during lifting of the dura mater. Following identification of the sphenoid ridge, orbital roof, and anterior clinoid process, the bone lateral to the orbital roof was drilled off until the dura mater of the anterior aspect of the temporal lobe was exposed. The dura mater of the temporal lobe was incised and opened, exposing the temporal pole under a 4-mm, 0° endoscope. Tumors in or around the temporal pole were safely removed under a superb view through the extradural corridor. The endoscopic extradural supraorbital approach was technically feasible and safe. The anterior trajectory to the temporal pole using the extradural space under endoscopy provided excellent visibility, allowing minimally invasive surgery. Further surgical experience and development of specialized instruments would promote this approach as an alternative surgical option.

ABBREVIATIONS ICA = internal carotid artery; MCA = middle cerebral artery.

Article Information

Correspondence Fuminari Komatsu, Department of Neurosurgery, Tokai University Hachioji Hospital, 1838 Ishikawa-machi, Hachioji, Tokyo 192-0032, Japan. email: fuminarikomatsu@gmail.com.

INCLUDE WHEN CITING Published online August 25, 2017; DOI: 10.3171/2017.3.JNS162228.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Schema of the endoscopic extradural supraorbital approach to the temporal pole. Upper: The blue area on the skull base indicates bone removal of the frontal and sphenoid bones to approach the temporal pole. The red area suggests the estimated bone removal area for the anterior clinoidectomy to expose the superior and lateral walls of the cavernous sinus. The endoscope is directed to the temporal pole through the supraorbital keyhole. Lower: Extradural space of the anterior and middle cranial fossa is seen through pinkish transparent bone to better understand the concept of this approach. The endoscope illuminates the anterior aspect of the temporal lobe dura through the extradural corridor via the supraorbital keyhole.

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    Case 1. MR images and endoscopic views of a temporal pole cavernous angioma (CA). A and B: Preoperative MR images show a 2-cm cavernous angioma (arrowheads) in the right temporal pole on T2-weighted (A) and Gd-enhanced (B) images. C: The sphenoid ridge (SR) and base of the anterior clinoid process (ACP) are displayed at the posterior edge of the anterior skull base. FD = dura mater of the frontal lobe; OR = orbital roof. D: The dura mater of the anterior aspect of the temporal lobe is exposed after drilling. MOB = meningoorbital band; TD = dura mater of the temporal lobe. E: The dura mater of the anterior aspect of the temporal lobe is opened, exposing the temporal pole (TP) in the intradural space. F and G: The cavernous angioma is visualized under an excellent endoscopic view (F), and complete removal is achieved (G). H: Postoperative T2-weighted MR image demonstrates complete removal of the tumor with minimum corticotomy from the anterior trajectory.

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    Case 2. MR images and endoscopic views of a sphenoid ridge meningioma (ME). A and B: Preoperative Gd-enhanced axial (A) and sagittal (B) MR images show a sphenoid ridge meningioma on the right. C: The endoscope is introduced into the extradural space of the anterior cranial fossa, and the sphenoid ridge (SR) and bone lateral to the orbital roof are drilled off. D: The frontotemporal dura mater attached to the tumor is widely exposed. There is a partial defect in the temporal dura mater due to the tumor. FD = dura mater of the frontal lobe; TD = dura mater of the temporal lobe. E: The frontal dura mater is incised along the margin of tumor attachment, and the tumor is detached from the frontal lobe (FL). F: The ICA is identified medial to the tumor. G: Branches of the MCA are severely adherent to the tumor, and adherent tumor is left behind. TL = temporal lobe. H: Postoperative axial Gd-enhanced MR image demonstrates subtotal removal of the tumor.

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    Case 3. MR images and endoscopic views of the cavernous sinus pituitary adenoma (PA). A and B: Preoperative Gd-enhanced coronal (A) and sagittal (B) MR images show residual tumor after multiple endonasal surgeries in the right cavernous sinus lateral to the ICA. Figure 4A modified from Komatsu F, Shimoda M, Oda S, Imai M, Shigematsu H, Komatsu M, et al: Identification of the internal carotid artery at the superior part of the cavernous sinus during endoscopic endonasal cavernous sinus tumor surgery. Acta Neurochir (Wien) 156:475–479, 2014, with permission from Springer. C: The endoscope visualizes the sphenoid ridge (SR) and base of the anterior clinoid process (ACP) in the extradural space of the anterior cranial fossa. D: The dura mater of the anterior aspect of the temporal lobe is partially exposed after drilling. TD = dura mater of the temporal lobe. E: The anterior clinoidectomy is performed under endoscopic visualization. F: After drilling, the extradural space is widely exposed through the supraorbital keyhole. The temporal and frontal dura mater, meningoorbital band (MOB), orbital roof (OR), optic nerve (II), and clinoidal triangle (CL; Dolenc triangle) are demonstrated. FD = dura mater of the frontal lobe; SOF = superior orbital fissure. G: The tumor is removed after the clinoidal triangle has been opened lateral to the optic nerve. H: The tumor is also removed through the anteromedial triangle (Mullan triangle) in the interdural space between the inner (IL) and outer layers (OL) of the lateral wall of the cavernous sinus. I: Tumor removal is accomplished without opening the intradural space. J: Postoperative Gd-enhanced MR image showing partial removal of the tumor (arrowheads).

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