The combined supra- and infratentorial approach for lesions of the petrous and clival regions; experience with 46 cases

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✓ The combined supra- and infratentorial approach has been subdivided into three variations: the retrolabyrinthine technique (petrous bone resection with preservation of hearing); the translabyrinthine technique (greater petrous bone resection and sacrifice of hearing); and the transcochlear technique (maximum petrous drilling, sacrifice of hearing, and transposition of the facial nerve). These three variations maximize temporal bone drilling and therefore provide exquisite exposure of the clivus and petrous regions with minimal or no brain retraction. The superior petrosal sinus is always sacrificed and the tentorium completely cut. The sigmoid sinus can be transected or kept intact, depending on the venous drainage and the degree of exposure required. A series of 46 patients who underwent the combined approach is presented.

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Address reprint requests to: Robert F. Spetzler, M.D., c/o Editorial Office, Barrow Neurological Institute, 350 West Thomas Road, Phoenix, Arizona 85013.

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Figures

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    Illustrations showing three variations of the combined supra- and infratentorial approach from the surgeon's viewpoint. Upper Left: Extended retrolabyrinthine approach with skeletonized posterior and superior semicircular canals and mastoidectomy. Upper Right: Translabyrinthine approach. All three semicircular canals have been removed. Lower: Transcochlear approach with posteriorly transposed facial nerve for maximum exposure.

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    Postoperative three-dimensional computerized tomography scans of bone reconstruction comparing petrous bone resection by the retrolabyrinthine approach (left) with total petrous bone resection by the transcochlear approach (right).

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    Illustration of the craniotomy with a broken line indicating dural incision with preservation of sigmoid sinus and clips across the superior petrosal sinus. An alternative dural incision (inset) crosses both superior petrosal and sigmoid sinuses.

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    Illustration showing the drainage system. If the sigmoid sinus is sacrificed, the ipsilateral vein of Labbé willdrain contralaterally, as it reliably enters the lateral sinus above the junction of the superior petrosal and sigmoid sinuses.

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    Illustration showing the temporal lobe and the cut tentorium protected by retractors. The base of the temporal lobe along with the cut tentorium is elevated without stretching the vein of Labbé. The ipsilateral petrous region, the entire clivus, and the cranial nerves are exposed.

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    Intraoperative photograph (left) and schematic drawing (right) after the translabyrinthine petrous bone resection. The sigmoid sinus has been transected and the dura of the temporal and posterior fossae has been opened. The tentorium will be cut along its entire length between the clips on the superior (sup.) petrosal sinus.

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    Intraoperative photograph (left) and schematic drawing (right) showing the exposure of the basilar artery and neck of the aneurysm among the fifth, seventh, and eighth cranial nerves. The sixth cranial nerve is draped over the aneurysm dome. Roman numerals denote cranial nerves; AICA = anterior interior cerebellar artery.

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    Left: Computerized tomography scan demonstrating a classic medium-sized meningioma suitable for the petrosal approach. It is located in both the middle and posterior fossae, straddling the petrous ridge. Center and Right: Magnetic resonance images demonstrating the extent of the tumor along the length of the clivus. The brain stem and the basilar artery are markedly elevated.

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    Intraoperative photographs (left) and schematic drawings (right) showing steps in the transcochlear approach. Roman numerals denote cranial nerves (C.N.'s). Upper: View after the petrous bone has been drilled. The sigmoid sinus and jugular bulb are exposed, and the superior (sup.) petrosal sinus can be seen entering the sigmoid sinus. The drilled-out seventh cranial nerve lies over the jugular bulb. The greater superficial petrosal branch has been cut to allow mobilization of the seventh cranial nerve. Compare the additional bone resection achieved with this transcochlear approach to that achieved with the translabyrinthine approach illustrated in Fig. 6. Center: View after the meningioma has been removed. The fifth through 11th cranial nerves and the basilar artery have been exposed. This very flat approach to the clivus can only be achieved through the transcochlear approach. Lower: A more anterior view exposing the third through eighth cranial nerves. Note the opened Meckel's cave where the residual tumor can now be easily removed.

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    Intraoperative photographs (left) and schematic drawings (right). Roman numerals denote cranial nerves (C.N.'s). Upper: Posteroanterior view after removal of a large clivus meningioma allowing excellent visualization of the hypophyseal stalk. Note the preserved fine vascular network on the brain stem. Maintaining the arachnoid over the brain stem to protect the vascularity is a primary goal when possible. ICA = internal carotid artery. Lower: Anteroposterior view after resection of a large meningioma providing a dramatic demonstration of the cranial nerves and vascular structure of this region. Post. comm. a. = posterior communicating artery; post. cerebral a. = posterior cerebral artery.

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