occurring temporosphenoidal encephalocele that was treated through an endoscopic endonasal approach. A detachable silicone balloon was used to push the cephalocele intracranially and then to secure the intrasphenoidal packing. Case Report History This 63-year-old woman presented with a 4-year history of nontraumatic intermittent leaking of CSF from the right nostril. The year before she was admitted to our department she underwent biopsy sampling and a second endoscopic endonasal procedure involving intrasphenoidal packing with fat graft and surgical glue
Alessandra Alfieri, Raffaele Schettino, Angelo Taborelli, Maurizio Pontiggia, Paolo Reganati, Valerio Ballarini and Luigi Monolo
Gabriel Zada, Daniel F. Kelly, Pejman Cohan, Christina Wang and Ronald Swerdloff
with the transseptal endonasal approach, postoperative complaints of pain and numbness were noted by 50 and 50% of patients, respectively, after the sublabial approach, and by 25 and 75% of patients, respectively, after the transseptal approach. 42 Details concerning the severity, location, and duration of these complaints, however, were not provided. Comparison With the Endoscopic Endonasal Approach Jho and Carrau 20 in 1997 and Jho 19 in 2001 reported their experiences with patients undergoing purely endoscopic endonasal surgery for a variety of sellar
Luigi M. Cavallo, Andrea Messina, Paolo Cappabianca, Felice Esposito, Enrico de Divitiis, Paul Gardner and Manfred Tschabitscher
The midline skull base is an anatomical area that extends from the anterior limit of the cranial fossa down to the anterior border of the foramen magnum. Resection of lesions involving this area requires a variety of innovative skull base approaches. These include anterior, anterolateral, and posterolateral routes, performed either alone or in combination, and resection via these routes often requires extensive neurovascular manipulation. The goals in this study were to define the application of the endoscopic endonasal approach and to become more familiar with the views and skills associated with the technique by using cadaveric specimens.
To assess the feasibility of the endonasal route for the surgical management of lesions in the midline skull base, five fresh cadaver heads injected with colored latex were dissected using a modified endoscopic endonasal approach.
Full access to the skull base and the cisternal space around it is possible with this route. From the crista galli to the spinomedullary junction, with incision of the dura mater, a complete visualization of the carotid and vertebrobasilar arterial systems and of all 12 of the cranial nerves is obtainable.
The major potential advantage of the endoscopic endonasal approach to the skull base is that it provides a direct anatomical route to the lesion without traversing any major neurovascular structures, obviating brain retraction. Many tumors grow in a medial-to-lateral direction, displacing structures laterally as they expand, creating natural corridors for their resection via an anteromedial approach.
Potential disadvantages of this procedure include the relatively restricted working space and the danger of an inadequate dural repair with cerebrospinal fluid (CSF) leakage and potential for meningitis resulting. These approaches often require a large opening of the dura mater over the tuberculum sellae and posterior planum sphenoidale, or retroclival space. In addition, they typically involve large intraoperative CSF leaks, which necessitate precise and effective dural closure.
Amin B. Kassam, Paul Gardner, Carl Snyderman, Arlan Mintz and Ricardo Carrau
The middle third of the clivus and the region around the petrous internal carotid artery (ICA) is a difficult area of the skull base in terms of access. This is a deep area rich with critical neurovascular structures, which is often host to typical skull base diseases. Expanded endoscopic endonasal approaches offer a potential option for accessing this difficult region. The objective of this paper was to establish the clinical feasibility of gaining access to the paraclival space in the region of the middle third of the clivus, to provide a practical modular and clinically applicable classification, and to describe the relevant critical surgical anatomy for each module.
The anatomical organization of the region around the petrous ICA, cavernous sinus, and middle clivus is presented, with approaches divided into zones. In an accompanying paper in this issue by Cavallo, et al., the anatomy of the pterygopalatine fossa is presented; this was observed through cadaveric dissection for which an expanded endonasal approach was used. In the current paper the authors translate the aforementioned anatomical study to provide a clinically applicable categorization of the endonasal approach to the region around the petrous ICA. A series of zones inferior and superior to the petrous ICA are described, with an illustrative case presented for each region.
The expanded endonasal approach is a feasible approach to the middle third of the clivus, petrous ICA, cavernous sinus, and medial infratemporal fossa in cases in which the lesion is located centrally, with neurovascular structures displaced laterally.
Luigi M. Cavallo, Andrea Messina, Paul Gardner, Felice Esposito, Amin B. Kassam, Paolo Cappabianca, Enrico de Divitiis and Manfred Tschabitscher
The pterygopalatine fossa is an area located deep in the skull base. The microsurgical transmaxillary–transantral route is usually chosen to remove lesions in this region. The increasing use of the endoscope in sinonasal functional surgery has more recently led to the advent of the endoscope for the treatment of tumors located in the pterygopalatine fossa as well.
An anatomical dissection of three fresh cadaveric heads (six pterygopalatine fossas) and three dried skull base specimens was performed to evaluate the feasibility of the approach and to illustrate the surgical landmarks that are useful for operations in this complex region.
The endoscopic endonasal approach allows a wide exposure of the pterygopalatine fossa. Furthermore, with the same access (that is, through the nostril) it is possible to expose regions contiguous with the pterygopalatine fossa, either to visualize more surgical landmarks or to accomplish a better lesion removal.
In this anatomical study the endoscopic endonasal approach to the pterygopalatine fossa has been found to be a safe approach for the removal of lesions in this region. The approach could be proposed as an alternative to the standard microsurgical transmaxillary–transantral route.
: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum Amin Kassam Carl H. Snyderman Arlan Mintz Paul Gardner Ricardo L. Carrau 7 2005 19 1 1 7 10.3171/foc.2005.19.1.5 FOC.2005.19.1.5 Extended endoscopic endonasal approach to the pterygopalatine fossa: anatomical study and clinical considerations Luigi M. Cavallo Andrea Messina Paul Gardner Felice Esposito Amin B. Kassam Paolo Cappabianca Enrico de Divitiis Manfred Tschabitscher 7 2005 19 1 1 7 10.3171/foc.2005.19.1.6 FOC.2005.19.1.6 Expanded endonasal approach: fully endoscopic, completely
Michael Schulder, Sussan Salas, Michael Brimacombe, Peter Fine, Jeffrey Catrambone, Allen H. Maniker and Peter W. Carmel
, intraoperative images revealing residual tumor, and the follow-up images with no visible tumor. T = target. Case 2 This 56-year-old woman presented with headache. On examination, she had a bitemporal hemianopia. Results of endocrine testing were normal, and diagnostic MR images revealed a pituitary macroadenoma invading the right cavernous sinus. This was demonstrated as well on the preoperative sagittal iMR image with axial and coronal reconstructions ( Fig. 3 left ). Surgery was performed via an endoscopic endonasal approach, followed by microsurgical resection. The
Mazhar Husain, Manu Rastogi, Bal Krishna Ojha, Anil Chandra and Deepak K. Jha
postoperative complications. References 1 Alfieri A , Jho HD , Tschabitscher M : Endoscopic endonasal approach to the ventral craniocervical junction: anatomical study . Acta Neurochir (Wien) 144 : 219 – 225 , 2002 2 Apuzzo ML , Weiss MH , Heiden JS : Transoral exposure of the atlantoaxial region . Neurosurgery 3 : 201 – 207 , 1978 3 Blazier CJ , Hadley MN , Spetzler RF : The transoral surgical approach to craniovertebral pathology . J Neurosci Nurs 18 : 57 – 62 , 1986 4 Cappabianca P , Alfieri A , de Divitiis E
Domenico Solari, Francesco Magro, Paolo Cappabianca, Luigi M. Cavallo, Amir Samii, Felice Esposito, Vincenzo Paternò, Enrico de Divitiis and Madjid Samii
and canals, through which many important neurovascular structures reach and cross over the pterygopalatine fossa. Thus, several neoplastic and inflammatory diseases of these surrounding areas can diffuse into the pterygopalatine fossa. 20 , 21 Most of the surgical procedures that have been used for the removal of lesions involving this area were extensive transcranial or transfacial approaches. 8 , 14 , 17 , 28 , 29 The use of an endoscopic endonasal approach has led neurosurgeons to evaluate the possibility of introducing this technique for the treatment of
fissure as seen during a pterional approach Mario Ammirati Antonio Bernardo 1 2007 106 1 151 156 10.3171/jns.2007.106.1.151 JNS.2007.106.1.151 Anatomical study of the pterygopalatine fossa using an endoscopic endonasal approach: spatial relations and distances between surgical landmarks Domenico Solari Francesco Magro Paolo Cappabianca Luigi M. Cavallo Amir Samii Felice Esposito Vincenzo Paternò Enrico de Divitiis Madjid Samii 1 2007 106 1 157 163 10.3171/jns.2007.106.1.157 JNS.2007.106.1.157 Intraoperative brain shift prediction using a 3D inhomogeneous patient