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Anatomical Basis of Skull Base Surgery:

Skull Osteology
CAROLINA MARTINS1,2, MD, PhD, ALVARO CAMPERO2, MD,
ALEXANDRE YASUDA2, MD, PhD, SHIGEYUKI OSAWA2, MD, PhD,
LUIZ FELIPE ALENCASTRO2, 3, MD, LUIZ CARLOS DE ALENCASTRO3, MD, PhD,
ALBERT RHOTON JR.2, MD
1
Medical School of Pernambuco IMIP, Recife/Brazil

Department of Neurosurgery, University of Florida, Gainesville
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Hospital Me de Deus, Porto Alegre, Brasil
2
Key words: Skull Base Osteology, Microsurgical Anatomy

Understanding the osteology of the skull base is a fundamental step in skull base
surgery. It allows for accurate topographic location and helps tailoring surgical routes to
specific skull base areas. This chapter reviews the osseous anatomy of the skull base, its
major divisions and components.
Introduction
The skull is divided into cranium and facial skeleton. The cranium, by its turn, is
divided into calvarium, which is the domelike superior portion of the cranium, formed
by the frontal, parietal and squamous parts of the occipital and temporal bones, and the
cranial base.
The cranial base has an endocranial surface, which faces the brain and is naturally
divided into anterior, middle and posterior fossae (Fig. 1) and an exocranial surface (Fig.
2), which faces the nasal cavity, sinuses, orbits, pharynx, infratemporal fossae and
pterygopalatine, parapharyngeal and infrapetrosal spaces.
On the endocranial side of the skull base, the border between the anterior and middle
fossa is marked the sphenoid ridge, joined medially by the chiasmatic sulcus, and the
border between the middle and posterior fossae is formed by the petrous ridges joined
by the dorsum sellae and posterior clinoid processes (Fig. 3).
On the exocranial side, the anterior and middle fossae are divided by a transverse line,
extending through the pterigomaxillary fissures and pterygopalatine fossae at the upper
level, and the posterior edge of the alveolar processes of maxilla at a lower level.
Medially, this corresponds to the attachment of vomer to the sphenoid bone. The
middle and posterior cranial fossae are separated on each side, by a transverse line
crossing near the posterior border of vomer-sphenoid junction, foramen lacerum,
carotid canal, jugular foramen, styloid process and mastoid tip (Fig. 4).
Anterior Skull Base

The anterior endocranial surface is formed by the combination of three bones:
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frontal, ethmoid and sphenoid (Fig. 5). The orbital plates of the frontal bones form most
of the lateral portions of this fossa, contributing to the roof of orbital cavities and
giving support to the dura and orbital gyri of the frontal lobe. The medial gap between
the orbital plates is filled by the cerebral surface of the ethmoid bone, presenting the crista
galli, which gives attachment to the falx and the cribriform plates, which, by its turn, gives
support to the olfactory bulbs. The anterior fossa is closed posteriorly by the lesser
wings of the sphenoid bone laterally, and the sphenoid body medially. In this way, the
medial portion of the anterior fossa is formed by three bones, while the lateral part, which
covers the orbit and optic canals, is formed only by two, the orbital plate of frontal bone
and the lesser sphenoid wing on each side.
On the exocranial side, the lateral portion of the anterior skull base is on the top of the
orbit and maxillary sinus. Medially, it corresponds to the sphenoid sinus of sphenoid body
and the ethmoid sinuses, on top of the nasal cavity (Fig. 6). In fact, the most posterior
portion of the medial exocranial anterior surface is related with the sphenoid, while the
medial and anterior thirds are related with the ethmoid bone.
The nasal septum, which is formed by vomer and perpendicular plate of ethmoid,
divides the nasal cavity along midline, while the lateral plates of the ethmoid bones divide
the nasal cavity from each orbit (Fig. 7, 8). Some foramina and grooves connect the endo
and exocranial surfaces in this area as the supraorbital grooves, on the superior orbital
limits, the ethmoid canals, located along the suture line formed by the frontal and
ethmoid bones, the superior orbital fissure between the lesser and greater sphenoidal
wings and optic canals, between the anterior and posterior roots of the anterior clinoid
processes.
Middle Skull Base

The endocranial surface of the middle fossa is formed by the sphenoid and temporal
bones. The division between these bones usually is not well seen unless focusing
attention to the sphenoid spine, the most posterior prominence of the sphenoid bone,
just behind the foramen spinosum and following the petro-sphenoidal and squamoussphenoidal sutures (Fig. 9). The sphenoid contributes to the middle fossa mainly with the
lateral parts of its body, the sphenoid crests and the greater wings. The sphenoid crest is
the posterior edge of the lesser sphenoid wings. The lesser wings connect across midline
through the sphenoid planum. The chiasmatic sulcus is located posterior to the planum.
On each side of the chiasmatic sulcus are the endocranial openings of the optic canals.
Posteriorly, the chiasmatic sulcus is separated from the sella cavity by the tubercullum
sellae. The posterior limit of sellae is comprised by dorsum and posterior clinoid
processes, which are the medial boundaries between the middle and posterior cranial
fossae (Fig. 10).
The largest opening at the greater sphenoid wing is the foramen ovale, which transmits
the third trigeminal division and, most of the times, the accessory meningeal artery.
Lateral to this opening is the foramen spinosum for the middle meningeal artery.
Occasionally there may be an opening medial to foramen ovale: the emissary sphenoid
foramen (foramen of Vesalius), which transmits a vein connecting the pterygoid venous
plexus and the cavernous sinus and, on occasions, might transmit the accessory
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meningeal artery. The lingula is a protrusion of the sphenoid bone located at the
junction of body and greater wing. As soon as the carotid artery leaves its canal on the
petrous portion of the temporal bone it is embraced by lingula, which holds the artery
in place, and allow it to run along the carotid sulcus on each side of sellae. Anteriorly, the
carotid artery rests against the optic strut, in close relationship with the anterior clinoid.
Lingula gives attachment to the petrolingual ligament that divides the horizontal petrous
carotid from vertical cavernous carotid segment (Fig. 11).
The endocranial surfaces of the petrous and squamosal parts of the temporal bone also
form the middle fossa (Fig. 12, 13). In this area, the greater petrosal nerve runs into the
facial hiatus just medial to tensor tympani muscle and lateral to the carotid canal. Next
to petrous apex there is the trigeminal impression which houses the trigeminal nerve.
Exocranially, the lateral middle fossa is related to the infratemporal, pterygopalatine
and infrapetrosal spaces, while the central part is divided into pharyngeal and
parapharyngeal spaces by a line passing through the medial pterygoid plate (Fig. 14, 15).
The lateral pterygoid plate is the anteromedial boundary of the infratemporal fossa, which
is separated from the temporal fossa by the infratemporal crest. The pterigomaxillary and
inferior orbital fissures, the alveolar canals, foramen spinosum, ovale and emissary
sphenoid foramen open into the infratemporal fossa. The exocranial surface of the
temporal bone is comprised between the mandibular fossa, petrous apex and mastoid tip.
In the center of this area are the styloid process and the stylomastoid foramen for the
facial nerve. From this area two grooves radiate: digastric groove, for the posterior
belly of the digastric muscle and the occipital groove for the occipital artery (Fig. 15). The
carotid canal is anterior to the jugular foramen and medial to external auditory meatus.
Posterior Skull Base

The endocranial surface of the posterior fossa is formed medially by union of the
sphenoid and clival portion of occipital bones. Laterally, it is composed by the apposition
of mastoid and the posterior surface of petrous portion of temporal bone with the
condylar and basal portions of the occipital bone (Fig. 16). The occipital bone is the major
osseous component of the posterior fossa. It is formed by a squamosal, condylar and basal
parts. The basal part fuses with the sphenoid to form clivus. Laterally, it articulates with
the temporal bone at the petroclival fissures. The squamosal part forms the posterior
boundary of the fossa and presents three angles. The superior angle fills the gap between
the parietals along the lambdoid suture. The lateral, paired angles mark the most lateral
extension of the lambdoid sutures and the ending point of the transverse sinus. It joins
the occipitomastoid and parietomastoid sutures at asterion, an important surgical
landmark for posterior fossa craniotomies.
The condylar part of the occipital bone forms a bridge between the squamosal and
basal parts (Fig. 17 & 18). The posterior surface of the petrous portion of the temporal
bone presents a medial area, containing the sulcus for the inferior petrosal sinus and a
lateral area comprising the jugular fossa and sulcus for the sigmoid sinus (Fig. 19). In the
articulated skull, the jugular fossa of temporal bone faces the jugular area of occipital
bone, while the anterior angle of occipital bone, located at the quadrilateral plate of the
jugular process adapts to the temporal bone lateral to the jugular fossa (Fig. 20 & 21), in
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such a way that the jugular process of the occipital bone forms the posterior lip of the
jugular foramen.
The occipital condyles are located on the exocranial surface of the condylar part of the
occipital bone (Fig. 22 & 23). In this area, basion is the midline point at the anterior arch
of foramen magnum, while the opisthion is the midline point at the posterior arch the
foramen. If the basion is considered 12:00 oclock and opisthion 06:00 oclock, the
occipital condyles can be projected in a position between 1-3 and 9-11:00 oclock.
Posteriorly, on top of the condyles are the supracondylar fossae, which house the
posterior opening of the posterior condylar canals. These canals transmit the posterior
condylar veins, which connect the vertebral venous plexus to the jugular bulb. The
anterior condylar veins, also called hypoglossal veins, course through the hypoglossal
canals.
The exocranial surface of the squamosal part of the occipital bone is marked by five
lines arranged around the external occipital protuberance (Fig. 23). Four of these are
transverse lines. The supreme nuchal lines are the highest ones, and give attachment to
the occipital aponeurosis. The superior nuchal line is just inferior to the previous ones.
From medial to lateral, it gives attachment to trapezius, splenius capiti and
sternocleidomastoid muscles. The vertical, unpaired line that radiates vertically from the
external occipital protuberance is the external occipital crest. It affords attachment to the
ligamentum nuchae and from its midpoint arise the inferior nuchal lines, which give
attachment to the superior oblique and rectus capitis posterior muscles.
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Fig. 1-4
1. Cranial base: endocranial surface. 2. Cranial base: exocranial surface. The upper surface of the
anterior cranial base is formed by the frontal bone, which roofs the orbit, the ethmoid bone, which is
interposed between the frontal bones and is the site of the cribriform plate; and the lesser wing and the
anterior part of the body of the sphenoid, which forms the posterior part of the floor of the anterior
fossa. The upper surface of the middle cranial base floor is formed by the greater sphenoid wing and
posterior two thirds of the sphenoid body anteriorly and the upper surface of the temporal bone,
posteriorly. The posterior part of the cranial base is formed by the temporal and occipital bones. The
exocranial surface is formed by the maxilla, the zygoma, palatine, sphenoid, temporal and occipital bones
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and vomer. The maxilla, orbits and the nasal cavity are located below the anterior fossa. The anterior
part of the hard palate is formed by the maxilla and the posterior part is formed by the palatine
bone. The anterior part of the zygomatic arch is formed by the zygoma and the posterior part, by the
squamosal part of the temporal bone. The mandibular fossa is located below the posterior part of the
middle fossa. The vomer attaches to the lower part of the body of the sphenoid and forms the
posterior part of the nasal septum. The infratemporal fossa is located below the greater sphenoid wing
and is limited anteriorly by the infratemporal crest. 3. On the endocranial side of the skull base, the limit
between the anterior and middle fossa is marked the sphenoid ridge, joined medially by the chiasmatic
sulcus (dotted light blue line), and the limit between the middle and posterior fossae is formed by the
petrous ridges joined by the dorsum sellae and posterior clinoid processes (dotted dark blue line). 4. On
the exocranial side, the anterior and middle fossae are divided by a transverse line, extending through
the pterigomaxilary fissures and pterygopalatine fossae at the upper level, and the posterior edge of the
alveolar processes of maxilla at a lower level. Medially, this corresponds to the attachment of vomer to
the sphenoid bone (dotted light blue line). The middle and posterior cranial fossae are separated on each
side, by a transverse line crossing near the posterior border of vomer-sphenoid junction, foramen
lacerum, carotid canal, jugular foramen, styloid process and mastoid tip (dotted dark blue line).
Fig. 5-8
5. The frontal ethmoid and sphenoid bones combine to form the anterior fossa, which is divided into
medial and lateral portions. The medial part, covering the upper nasal cavity and sphenoid sinus, is
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formed by the crista galli and the cribriform plate of the ethmoid bone anteriorly and the planum of the
sphenoid body posteriorly. The lateral part, which covers the orbit and the optic canal, is formed by the
frontal bone and the lesser wing of the sphenoid bone, which blends medially into the anterior clinoid
processes and point towards the middle fossa. 6. On the exocranial side, the anterior cranial base is
divided into a medial part related to the ethmoidal and sphenoidal sinuses and nasal cavity below, and
a lateral part that corresponds to the orbit and maxilla. The ethmoid bone forms the anterior and middle
thirds of the exocranial surface and the sphenoid body forms the posterior third of the medial part. The
ethmoid presents the perpendicular plate that joins the vomer in forming the nasal septum and two
lateral plates located in the medial wall of the orbits. The lateral plates separate the lateral wall of the nasal
cavity and the orbit. The main foramina of the region are the anterior and posterior ethmoidal
foramina located in the superomedial orbital wall, along the frontoethmoidal suture, which transmit
the ethmoidal nerves and arteries, the supraorbital and supratrochlear notches or foramina, transmitting
the arteries and nerves of the same name, and the optic canal which transmits the optic nerve and
ophthalmic artery. The superior orbital fissure is located between the lesser and greater sphenoidal wings
on the lateral side of the optic canal. It transmits the oculomotor, trochlear, ophthalmic, and abducens
nerves, a recurrent meningeal artery, and the superior and inferior ophthalmic veins. 7. The osseous nasal
septum is formed by the attachment of the perpendicular ethmoid plate and vomer at the sphenoidal
crest. 8. Anterior norma. The orbital rim is formed by the frontal bone, zygoma and maxilla. The nasal
bone is interposed above the anterior nasal aperture, between the maxillae. The nasal cavity is located
between the ethmoid bone above and the maxillae, palatine bones, and sphenoid pterygoid process
below. It is roofed by the frontal and ethmoid bones and the floor is formed by the maxillae and palatal
bones. The nasal septum forms the medial walls of the nasal cavities. The nasal conchae are located on
the lateral walls of the nasal cavity. The inferior concha (insert) is a separate bone, and the middle and
superior concha are appendages of the ethmoid bone.
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Fig. 9-13
9. The endocranial surface of the middle cranial base is formed by the sphenoid and temporal bones
and can be divided into three regions: a medial part, the sellar region (blue shaded area), formed by the
sphenoid body; a lateral part, the temporal fossa (pink shaded area), formed by the sphenoidal wings
and the cerebral surface of the squamosal and petrous parts of the temporal bone, and an intermediate
part, the parasellar area (yellow shaded area), formed by the transitional part of the sphenoid bone
between the greater wing and body, and receiving posteriorly a small contribution of the petrous apex
of the temporal bone. The greater wing forms the largest part of the endocranial surface of the middle
fossa, with the squamosal and the petrosal parts of the temporal bone completing this surface. 10.
Enlarged view of the medial part of the middle fossa. The medial part of middle fossa is formed by the
body of the sphenoid bone. 11. Lateral view of the parasselar region. The course of the petrous,
cavernous and supraclinoid carotid have been represented. The cavernous sinus sits on the lateral aspect
of the body of the sphenoid bone. The carotid sulcus is the shallow groove on the lateral aspect of the
body of the sphenoid bone along which the cavernous carotid courses. The cavernous carotid sits against
and is separated from the carotid sulcus by the dura of the medial sinus wall. The carotid sulcus begins
inferior and lateral to the dorsum sellae at the intracranial end of the carotid canal, turns forward to
groove the body of the sphenoid immediately below the lateral edge of the floor of the sella, and turns
upward to end medial to the anterior clinoid process. 12. The upper surface of the petrous bone is
grooved along the course of the greater and lesser petrosal nerves. The lesser petrosal nerve from the
tympanic plexus passes through the tympanic canaliculus, which is located anterior to the facial
hiatus and courses in an anteromedial direction parallel to the greater petrosal nerve, which courses along
the facial hiatus. The carotid canal extends upward and medially and provides passage to the internal
carotid artery and carotid sympathetic nerves in their course to the cavernous sinus. The posterior
trigeminal root reaches the middle fossa and, at the trigeminal impression, on the upper surface of the
petrous bone, are located Meckels cave and the semilunar ganglion. The arcuate eminence approximates
the position of the semicircular canals. The internal auditory canal can be identified below the floor of
the middle fossa by drilling along a line approximately 60 degrees medial to the arcuate eminence, near
the middle portion of the angle between the greater petrosal nerve and arcuate eminence. The petrous
apex, medial to the internal acoustic meatus, is free of important structures. A thin lamina of bone, the
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tegmen tympani, extends laterally from the arcuate eminence and roofs the mastoid antrum and
tympanic cavities and the canal for the tensor tympani. Opening the tegmen from above exposes the
heads of the malleus, incus, the tympanic segment of the facial nerve, and the superior and lateral
semicircular canals. 13. The anterior surface of the temporal bone has been drilled to expose the
internal structure of the temporal bone. The carotid artery is represented in red, the facial nerve in
yellow, the cochlear nerve in black and the vestibular nerves in green. The arcuate eminence
approximates the position of the superior semicircular canal; however, the relationship between these
two structures is greater at their anterior end, from which their main axis diverge. From the brainstem
to its peripheral branches, the facial nerve can be divided into six portions: cisternal, meatal (a),
labyrinthine, tympanic, mastoid (c) and extracranial. The labyrinthine segment, which is located in the
petrous part, extends from the meatal fundus to the geniculate ganglion and is situated between the
cochlea anteromedially and the semicircular canals posterolaterally. The labyrinthine segment ends at
the site at which the greater superficial petrosal nerve arises from the facial nerve at the level of the
geniculate ganglion. From there, the nerve turns laterally and posteriorly along the medial surface of the
tympanic cavity, thus giving the name tympanic segment to that part of the nerve. The tympanic segment
runs between the lateral semicircular canal above and the oval window below. As the nerve passes below
the midpoint of the lateral semicircular canal, it turns vertically downward and courses through the
petrous part adjacent to the mastoid part of the temporal bone; thus the third segment, which ends at
the stylomastoid foramen, is called the mastoid or vertical segment. Into the temporal bone the facial
nerve gives off the greater petrosal (e) and chorda tympani nerves (f). The corda tympani nerve,
which arises from the mastoid part, runs upwards, passes along the roof of the tympanic cavity and exits
the cavity through the anterior canaliculus. The greater petrosal nerve runs initially along the facial hiatus
runs beneath the dura of the middle fossa, reaches the sphenopetrosal groove formed by the junction
of the petrous and sphenoid bones, immediately superior and anterolateral to the horizontal segment
of the petrous carotid and joins the sympathetic carotid nerves to help forming the vidian nerve into
the pterygoid canal. The cochlea lies below the floor of the middle fossa in the angle between the
labyrinthine segment of the facial nerve and the greater petrosal nerve, just medial to the geniculate
ganglion, anterior to the fundus of the internal acoustic meatus, and posterosuperior to the lateral genu
of the petrous carotid artery.
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Fig. 14-15
The exocranial surface of the middle cranial base is also divided into medial (blue shaded area),
intermediate (yellow shaded area) and lateral (pink shaded area) parts. The medial part encompasses
the sphenoid body and the upper portion of the basal (clival) part of the occipital bone and corresponds
to the sphenoid sinus and the nasopharynx. The lateral part is formed by the greater sphenoid wing, the
petrous, tympanic, and squamous and styloid parts of the temporal bone and the zygomatic, palatine,
and maxillary bones. The intermediate part corresponds to the area comprised between the pterygoid
plates, encompassing the area inferior to the cavernous sinuses, which extend from the pterygopalatine
fossa in front to the pterygoid fossa posteriorly. 15. Temporal bone. Exocranial surface.The temporal
bone is divided into squamosal, petrous, mastoid, tympanic, and styloid parts. The tympanic and
squamosal parts, which form the roof of the mandibular fossa, are located anteriorly to the styloid part,
the mastoid part is postero-lateral, radially grooved by the occipital groove and mastoid notch, and the
petrous part is located medial to the styloid part.
Fig. 16-19
16. The posterior cranial base is formed by three bones: sphenoid, temporal and occipital bones. The
posterior fossa can be divided into medial and lateral portions. Medially, the sphenoid and the basal
(clival) portion of occipital bone fuse at the sphenoclival syncondrosis. Laterally, the posterior fossa is
composed by the apposition of mastoid and posterior surface of petrous portion of temporal bone with
condylar and basal portions of the occipital bone. The occippital bone is the main component of the
posterior cranial fossa. It has three parts, clival, condylar and squamosal; three borders, petrous,
mastoid and parietal and three angles: paired, anterior and lateral angles, and an unpaired, superior
angle. The anterior angle marks the combination of the different parts of temporal and occipital
bones: medial to the anterior angle, the petrous border meets the petrosal part of the temporal bone at
the petroclival fissure, and the jugular fossa of the temporal bone combines with the jugular notch of
the occipital bone to form the jugular foramen. Lateral to the anterior angle, the mastoid border meets
the mastoid part of the temporal bone to form the occipitomastoid suture. The parietal border,
between the lateral and superior angle, combines with the parietal bone forming the lambdoid suture.
17. Superior view of the endocranial side of the condylar and basal (clival) parts of the occipital
bone. The condylar part can be considered a bridge connecting the clival and squamosal parts of the
occipital bone. The clival part is concave from side do side and present the sulcus for the inferior petrosal
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sinus. The inferior petrosal sinus links the cavernous sinus to the medial part of the jugular foramen.
On the exocranial side, there is a similar sulcus for the inferior petrosal vein. The condylar part
comprises a quadrilateral plate of bone, the jugular process, whose anterior border presents the
jugular notch and the anterior angle of the occipital bone. Medial to the jugular notch, on the
endocranial surface is the jugular tubercle, a protrusion related to the course of the lower cranial nerves.
18. Exocranial surface of the condylar part of the occipital bone. The jugular notch is located
superolateral to the hypoglossal canal and occipital condyle. On its posterior wall there is the opening
of the posterior condylar canal, which transmits an emissary bvein connecting the vertebral plexus to
the sigmoid sinus. The hypoglossal canal can be divided by a fibrous or a bony septum. 19. The
posterior surface of the temporal bone forms the anterolateral limit of the posterior fossa. It extends from
the petrous apex medially to the sigmoid sulcus laterally and from the sulcus for the superior petrosal
sinus and petrous ridge superiorly, to the sulcus for the inferior petrosal sinus and jugular fossa
inferiorly. The nerves passing through the internal acoustic meatus have been represented with
colored material: the facial nerve (yellow) is located anterosuperior, the cochlear nerve (black) is
anteroinferior, and the vestibular nerves are located posterolaterally. The petrous carotid (red) is
represented in the carotid canal.
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Fig. 20-23
20. Petroclival area. The combination of the basal (clival) part of the occipital bone and petrosal part
of the temporal forms the petroclival fissure. The combination of the jugular notch of the occipital bone
and the jugular fossa of the temporal forms the jugular foramen. The intrajugular processes of the
temporal and occipital bones project into the jugular foramen and divide this area into petrosal and
sigmoid parts. The intrajugular process of the temporal bone is usually more prominent. 21.
Arrangement of parietal, temporal and occipital bones on the right side of the skull. Lateral to the jugular
foramen, the mastoid border of the occipital bone meets the mastoid part of the temporal bone,
forming the occipitomastoid suture. The parietal bone meets the mastoid part of the temporal at the
parietomastoid fissure and the parietal border of the occipital bone combines with the parietal bone at
the parieto-occipital or lambdoid suture. The meeting point of the occipitomastoid, parietomastoid and
lambdoid sutures forms the asterion. The asterion is related to the lateral angle of the occipital bone and
marks the transition between the transverse and sigmoid sinuses at the most lateral part of the
posterior cranial fossa. 22. The occipital bone surrounds the foramen magnum. The occipital bone is
divided into a squamosal part located above and behind the foramen magnum, a basal (clival) part
situated in front of the foramen magnum, and paired condylar parts, located lateral to the foramen
magnum. Basion is the most anterior part of the anterior edge of foramen magnum. Opisthion is the
most posterior point along the posterior edge of foramen magnum. 23. Exocranial surface of squamosal
part of the occipital bone.The exocranial surface is marked by four paired transverse ridges and one
vertical crest that radiate from the external occipital protuberance. The supreme nuchal lines are the
highest ones, and give attachment to the occipital aponeurosis. The superior nuchal lines are just inferior
to the previous ones, and usually more marked. From medial to lateral, they give attachment to
trapezius, splenius capiti and sternocleidomastoid muscles. The superior nuchal lines have a transverse
part, close to the external occipital protuberance. Laterally, close to the mastoid, they describe an arched
course, related to the mastoid emissary foramina. The transverse part of the superior nuchal line marks
externally the position of the transverse sinuses and the transition between the supratentorial and
infratentorial compartments. The external occipital crest radiates vertically from the external occipital
protuberance close to midline. It affords attachment to the ligamentum nuchae. From the midpoint of
the external occipital crest, an arched paired ridge, the inferior nuchal line radiates, just above the
posterior edge of foramen magnum. The inferior nuchal line on each side gives attachment to the
superior oblique and rectus capitis posterior major and minor. The occipital bones sit over the
cervical atlas adapting the convex occipital condyles adapt to the concavity of the lateral masses of atlas
and piling on top of the cervical column.
Ant.: Anterior, Ac.: Acoustic, Arc.: Arcuate, Can.: Canaliculus, Car.: Carotid, Cav.: Cavity, Chiasm.:
Chiasmatic, Clin.: Clinoid, Cond.: Condyle, Condylar, Em.: Emmissary,Emin.: Eminence, Eth.: Ethmoid,
Ethmoidal, Eust.: Eustachian, Ext.: External, Fiss.: Fissure, For.: Foramen, Front.: Frontal, Gr.: Greater,
Horiz.: Horizontal, Hypogl.: Hypoglossal, Impres: Impression, Inf.: Inferior, Infratemp.: Infratemporal, Int.:
Internal, Intrajug.: Intrajugular, Jug.: Jugular, Lat.: Lateral, Less.: Lesser, Mand.: Mandibular, Mast.:
Mastoid, Mid.: Middle, Occip.: Occipital, Occipito, Orb.: Orbital, Palat.: Palatine, Par.: Parietal, Pet.:
Petrous, Perp.: Perpendicular, Pharyng.: Pharyngeal, Post.: Posterior, Proc.: Process, Pteryg.: Pterygoid,
Pterygomax.: Pterygomaxillary, Subarc.: Subarcuate, Sem.: Semicircular, Sphen.: Sphenoid, Sphenoidale,
Squam.: Squamous, Squamotymp.: Squamotympanic, Sup.: Superior, Supraorb.: Supraorbital, Surf.:
Surface, Sut.: Suture, Supracond.: Supracondylar, Supraorb.: Supraorbital, Sig.: Sygmoid, Stylomast.:
Stylomastoid, Temp.: Temporal, Trig.: Trigeminal, Tymp.: Tympanii, Tympanic, Tuberc.: Tubercle,
Transv.: Transverse, Vest.: Vestibular, Zyg.: Zygomatic.
REFERENCES
1. Rhoton Al Jr. The posterior cranial fossa. Microsurgical anatomy and surgical approaches.
Neurosurgery 47(1):S1-S298, 2000.
2. Rhoton AL Jr. The supratentorial cranial space. Microsurgical anatomy and surgical
approaches. Neurosurgery, 51(1):S375-S410, 2002.
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Principles and practice of skull base

surgery
MADJID SAMII1, MD, PhD; VENELIN M. GERGANOV2, MD, PhD
1
President - International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625

Hannover, Germany
2
Associate Neurosurgeon, Department of Neurosurgery, International Neuroscience
Institute-Hannover
Key words: scull base surgery, endoscopic assistance, intraoperative neuronavigation,
frontolateral approach, retrosigmoid suprameatal approach, Samiis
approach
Most cranial base tumors are benign and do not invade adjacent structures. Their
complete removal may lead to cure of the patient. However, because of the complex
structure of the cranial base and the close proximity of the lesion to cranial nerves
and vessels, surgery in this area is associated with considerable risk of morbidity and even
mortality. The management of such lesions still remains a challenge, despite the
enormous progress over the past few decades, which made it more efficient and safe.
Some four decades ago many areas in the skull base were regarded as no mans land. The
neurosurgeon was unable to provide adequate treatment for a considerable number of
basal lesions. At that time a close cooperation with specialists in the area of neurosurgery,
ENT, maxillofacial surgery, and ophthalmology was initiated. Receiving the input from
each one of them, skull base surgery was established, soon proving to be one of the most
rapidly developing surgical fields. The principle of interdisciplinary cooperation remains
a main feature of this field of surgery. The establishment of endoscopy, either as a sole
procedure or as endoscopic assistance to the microsurgical technique, is a recent
example of how the ongoing cooperation leads to new concepts of treatment.
The goal of skull base surgery is the achievement of complete tumor removal.
However, another generally accepted principle is the preservation of neurological
functions and quality of life after surgery. In case of malignant tumors, it might be
necessary to sacrifice some functions in order to achieve oncological resection. In
benign tumors, however, sound judgment is required to decide when to stop and avoid
severe deficits. An integral part modern skull base surgery is the restoration or
reconstruction of lost functions.
Nowadays, any skull base lesion can be successfully approached and removed with very
low mortality risk, acceptable morbidity rates and increasing rate of preservation of
neurological functions. Multiple approaches to each part of the skull base have been
developed and put into practice, ranging from small modifications of more traditional
approaches to complex and sophisticated new techniques. One tendency was to promote
wide bone resections, characteristic of the skull base approaches, and thus to avoid
excessive brain retraction and the related complications. Another tendency was to
make smaller craniotomies and to be less invasive in regard to the skull opening, at the
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expense of restricting the operative view, increasing the risks of injury to adjacent
structures and limiting the completeness of tumor removal. The senior authors (MS)
experience in this area, encompassing more than 40 years, has shown that achievement
of optimal outcome requires utilization of approaches that are not by themselves related
to significant approach-related morbidity and provide sufficient access (1). Simpler
approaches, individually targeted to each lesion and patient, lead to optimal outcomes.
Thus, the refinements of the traditional retrosigmoid suboccipital approach have made
it the most effective and safe approach, the golden standard for lesions in the
cerebellopontine angle (CPA). On the other hand, in some basal tumors, e.g. chordomas
and chondrosarcomas, the approach has to be selected individually and always tailored
to the characteristics of the particular tumor, its location and patient's expectations.
Achievements in neuroradiology, neuroanesthesia, electrophysiology, microsurgery,
as well as the technological progress, all contributed to the establishement of skull base
surgery. The advances of neuroimaging contributed significantly to decreasing the risks
of surgery. Besides information on the tumor type, an adequate neuroradiological
study should allow an accurate visualization of the tumor location and extension, as well
as the relation to surrounding structures. A detailed study of the structure of adjacent
areas of the skull base is an essential component of the approach planning. The
knowledge of the anatomical variations is a prerequisite for the safe performing of the
procedure. Preoperative angiography provides essential information regarding the
vascular supply to the tumor, relation to major vessels or sinuses, and hemispheric
dominance. In case of highly vascular tumors, such as hemangiopericytomas, glomus
jugulare tumors, and some menigiomas, preoperative embolisation of tumor vessels
might be of great help.
The application of intraoperative neuronavigation has become a routine in
neurosurgery. In skull base surgery it allows for accurate approach planning and for
intraoperative localization of important bone, brain and vascular structures, thus
increasing the safety of surgery (Fig.1). The tumor location and extension can be
visualised in real time and the completeness of resection can be controlled. It is especially
helpful in those cases when the normal anatomical landmarks are difficult to identify or
had been lost: when working via a narrow corridor such as the endonasal (Fig.2); in
tumors causing wide bone destruction; in case of previous radiotherapy; or in
reoperations. The technique is very reliable and accurate throughout the procedure due
to the absence of the brain shift at the skull base level.
Radiosurgery cannot lead to a cure; however, it can provide long-term tumor control
and is an additional option in case surgery cannot lead to complete tumor removal or is
too risky. The cooperation between neurosurgeons and radiosurgeons allows for the
optimal selection of an individual patients management. The increasing experience
has shown that operative treatment after previous radiosurgery is much more difficult
and dangerous. Further, it frequently hinders radical tumor removal; therefore, surgery
should have a priority. In case a tumor portion cannot be completely removed without
major deficits, this residual can be treated with radiosurgery. In other cases, such as small
meningiomas or tumor remnants limited to or invading the cavernous sinus, radiosurgery
may be the first treatment choice (2,3).
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Skull Base
Fig. 1a
Fig. 1b
Fig. 1c
Fig. 1d
Fig. 1 Petrous apex chondrosarcoma - T1- weighted MRI (Fig.1a), bone-window
CT (Fig.1b). The tumor was approached via the subtemporal extradural route. The
bone overlying the tumor in the petrous apex is resected and the petrous internal
carotid artery (ACI) and tumor are visible (Tu) - Fig. 1c. The neuronavigation image
shows good corresponds to the intraoperative view (red - petrous internal carotid
artery; yellow - tumor) - Fig.1d. The bone structures are also well demonstrated due
to the fusion between MRI and bone-window CT data.
Anterior and middle cranial base

Tumors of the anterior cranial base are either primarily intracranial or extracranial with
secondary involvement of the skull base. Surgery is the primary treatment mode for
benign tumors, while in malignant tumors it is a part of the multimodal management.
Extracranial approaches are indicated if the tumor does not penetrate the dura. Extensive
transbasal or combined intra- and extracranial approaches even with orbital exenteration
may be indicated in aggressive tumors. The introduction of endoscope assistance and the
elaboration of the extended endonasal surgical technique is a recent advancement. The
possibility of the endoscope to look around the corner, their great illumination power and
wide viewing angle, allow access to tumors of the whole cranial base, from the crista galli
to C2 level (4,5,6). Its major advantage are the avoidance of craniotomy and of brain
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Fig. 2 Extended endonasal endoscopic

approach with a navigational guidance
to a extensive skull base chordoma.
retraction and the direct approach to the feeding vessels of the tumor. The technique,
however, has several drawbacks that make manipulations and dissection close to critical
structures more dangerous. Its actual indications, especially in the surgery of the
anterior skull base, remain to be defined.
The intracranial approaches to this part of the skull base are either extradural or
intradural. For tumors with both intra- and extracranial extension, such as
esthesioneuroblastomas, a combined approach may be necessary. The intracranial
tumor part is removed via the frontolateral route which allows for safe dissection from
the brain under direct observation and for reconstruction of the dural defect with a galeaperiosteal ap or fascia temporalis. The extracranial extension is removed via an
endoscopic or endoscope-assisted endonasal approach at a second stage.
The traditional intradural approach to the anterior skull base and the suprasellar area
required a bifrontal or unilateral subfrontal craniotomies because the wide exposure was
considered essential. In some cases, however, it can cause severe neurological impairment
due to frontal lobe retraction, especially if bilateral. The occlusion of the superior
sagittal sinus and of the bridging veins may have unpredictable sequelae. To avoid this
complication, low basal approaches with removal of the supraorbital rim have been
introduced. Increasing experience has shown that the simple frontolateral and
frontotemporal (pterional) approaches provide sufficient access to tumors of the
anterior cranial fossa, and the supra- and parasellar regions. Either of these approaches
avoids the approach-related morbidity of the more extensive and complex approaches,
which are time consuming, require inevitable opening of the frontal sinus, and endanger
the venous structures. The craniotomy is relatively small but allows to visualize the
important structures and provides enough room for safe tumor dissection. With
adequate positioning of the patient's head and early cerebrospinal uid release, the
need for brain retraction is obviated.
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The frontolateral approach

This simple and safe procedure could be regarded as a modification of the
frontotemporal (pterional) approach, including only its frontal part, or as a minimally
invasive version of the unilateral subfrontal approach (7). The main advantages of the
frontolateral approach are its simplicity and exibility. The skin is incised behind the hair
line, starting anterior to the tragus and reaching the midline at the anterior edge of the
hairline. The scalp is elevated to the supraorbital rim and the frontozygomatic suture. The
size of the craniotomy, which is cut just above the supraorbital margin, is usually 25 to
35 mm in width and 20 to 25 mm in height (Fig.3). Laterally, the craniotomy extends to
the key point where a single burr hole is made. In the medial direction, it should reach
the supraorbital notch, avoiding injury to the supraorbital nerve and artery. The
craniotomy could be modied according to the size of the frontal sinus - its opening
should be avoided. In case of large sinus that is widely entered, its mucosa should be
exenterated, and its integrity should be reconstructed at the end with a pericranial
ap. The dura is incised in a semicircular manner with an inferior base and sutured
Fig. 3a frontolateral craniotomy.
Fig.3b a meningioma (Tu) arising from the anterior clinoid

process (ACP) is seen.
Fig. 3c complete tumor removal with preservation of the

optic nerve (II) vaculature (ICA- internal carotid artery).
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forward. Excessive retraction of the frontal lobe can be avoided by initial draining of
sufficient amount of CSF from the basal cisterns. Via this route, meningiomas originating
from the olfactory groove, tuberculum sellae, planum sphenoidale, diaphragm sellae, and
anterior clinoid, as well as other tumors, such as pituitary macroadenomas and
craniopharyngiomas, can be successfully removed, and this has been our favorite
approach in the past decade.
Tumors expanding toward the middle cranial fossa, such as medial sphenoid wing
meningiomas, are better accessed via the classical frontotemporal route (8).
Cerebellopontine angle and Petroclival area

The retrosigmoid suboccipital approach is the most flexible and safe approach to the
cerebellopontine angle and allows for adequate access and removal of any lesion
developing in that area (1). The technique of the approach has been presented in detail
in the Vestibular Schwannoma Chapter.
Tumors of the petroclival area - typically meningiomas or trigeminal schwannomas
- remain difficult to treat with acceptable mortality and morbidity rates. On the other
hand, the natural evolution of these tumors is characterized by progressive growth
and neurological deterioration, and an attempt at surgical removal is therefore justied
(9). The history of petroclival meningioma surgery to a large extent reflects the evolution
of skull base surgery. Initially complete visualization of both the tumor and all adjacent
structures was regarded as a prerequisite for making surgery more feasible and safer.
Multiple extensive skull base approaches have been described for their management: the
combined supra-infra-trans-tentorial approaches; the combined retrosigmoidsubtemporal-trans-tentorial approach with and without ligation of the sigmoid sinus; the
intradural or epidural subtemporal approach with resection of petrous apex; the petrosal
approaches differing in the degree of removal of the pyramid: the presigmoid approach,
the retrolabyrinthine petrosectomy, the translabyrinthine petrosectomy, and the
complete petrosectomy which includes removal of the whole labyrinth and requires
transposition of the facial nerve (10-16). The advantages of lateral skull base approaches
are: shorter distance to the tumor and surrounding neurovascular structures, improved
visualization, and minimazed brain retraction (17,18). These extended approaches,
however, have an unacceptably high approach-related mortality, with a high rate of facial
nerve palsy, hearing loss and CSF leaks. Another main disadvantage is the risk of injury
to the highly variable venous structures, e.g. the vein of Labbe, or any of the major
draining veins, might have unpredictable and devastating consequences.
The retrosigmoid-suprameatal or Samii`s approach was developed as an effective
alternative with few approach-related complications (1,19,20). It provides access to
the Meckels cave, petroclival area and the middle fossa including the posterior cavernous
sinus. Another advantage of the approach is the possibility of identifying the abducent
nerve early at its brain stem exit zone, and following it during tumor removal up to the
Dorello's canal.
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Retrosigmoid- suprameatal approach (Samii`s approach)

The approach that was introduced in 1982, makes use of the simple and safe
retrosigmoid craniotomy, combined with a resection of the petrous apex and eventually
incision of the tentorium. The positioning of the patient and the details of the
retrosigmoid craniotomy are similar to those described for the cerebellopontine angle
tumors. The removal of petroclival tumors is based on the concept of the CPA levels or
corridors: between the tentorium and the trigeminal nerve; between the trigeminal
and the 7-8th nerves complex; between the 7-8th nerves and the caudal nerves; or- more
rarely - between the caudal nerves and foramen magnum. Their removal should start
initially at the most expanded level, with the widest distance between the respective
structures. The tumor is debulked partially using the CUSA, and only after that is the next
level approached.
The petrous apex is then resected by intradural drilling of the suprameatal tubercle the bone located above and anterior to the IAM. The drilling permits to extend the
retrosigmoid approach as far as 13.0 mm anterior when compared to the retrosigmoid
approach alone. Drilling permits extension of the retrosigmoid approach as far as 13.0
mm anterior, compared with the retrosigmoid approach alone (21). Opening Meckel's
cave allows for mobilization of the trigeminal nerve, which further increases the working
space. The incision of the tentorium provides access to tumor extension in the middle
cranial fossa.
A staged surgery may be indicated if the tumor has a large supratentorial extension,
which compresses or engulfs the optic nerve, the carotid artery, or the oculomotor
nerve. Initially, the tumor part in CPA, clivus, and/or Meckels cave is removed via the
Samii`s approach, the brain stem is decompressed and the risk of severe neurological
deterioration is thus prevented; the supratentorial portion is removed at a second stage
via frontotemporal route. If the vision is deteriorating, the supratentorial part of the
procedure is performed first.
Frequently the tumor has already significantly displaced the brain stem and an
adequate route even to the contralateral side or supratentorially is provided. Utilizing the
transtumoral routes approach, the risks of additional morbidity of complex skull
base approaches could be avoided. In petroclival meningiomas, the access to the rostral
tumor part is prepared by the tumor itself and can be further enlarged by resection of the
tentorium.
Foramen magnum
The selection of an approach to this area depends on several factors, such as tumor size,
location and type, extent of osseous involvement, and neurological status of the patient
(22). Nonetheless, of paramount importance is the location of the tumor in relation to
the dura. Posteriorly located tumors are approached via a medial bilateral suboccipital
craniectomy and C1 laminectomy if necessary. All other intradural tumors can be
successfully removed via the lateral suboccipital route, which combines a retrosigmoid
craniectomy and a C1 hemilaminectomy/laminectomy (23) - Fig.4. To achieve adequate
access to the tumor C1 lamina should be resected sufficiently and the foramen magnum
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Fig. 4a
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Fig. 4b
Fig. 4a Foramen magnum meningioma, exposed via a retrosigmoid craniectomy

and a C1 laminectomy; Fig.4b: view after complete tumor removal. (C- cerebellum
, Tu- tumor, *- vertebral artery).
should be opened wide.

Complete dissection or transposition of the vertebral artery is dangerous and timeconsuming procedures of less practical signicance. The far lateral approaches include
extensive posterior and lateral bone resection with varying degrees of drilling of the
occipital condyle (the transcondylar approaches) and are claimed to provide the best
avenues to the lower clivus, anterior foramen magnum, and premedullary area (24,25).
The morbidity rate with these approaches, however, is high and is related to vascular
complications, injury to cranial nerves, CSF leak, or instability. The lateral suboccipital
approach with the patient in the semisitting position (described above) is a safer and
simpler alternative. The tumor itself creates the corridor sufcient for its removal, and
extensive bone removal with the associated morbidity can usually be avoided. Only in
exceptional cases, such as small meningiomas located purely in the midline, have we
found it necessary to resect the posterior third of the occipital condyle. The selection of
the optimal approach to extradural tumors of the anterior foramen magnum depends on
their mediolateral and craniocaudal growth. In clival lesions that do not extend laterally
from the condyle or into the CPA, we favor the endonasal approach with endoscopic
assistance. It provides sufficient exposure to the whole clivus and down to the C2 level.
Tumors that grow more laterally or penetrate the dura are accessed via a lateral
suboccipital approach, and the tumor is removed both extra- and intradurally. For
aggressive tumors with signicant bone involvement, such as some chordomas, the
pyramid or the condyle, which is already partially eroded, is widely drilled off.
REFERENCES
1. Al-Mefty O, Fox JL, Smith RR: Petrosal approach for petroclival meningiomas.
Neurosurgery 22:510-517, 1988
2. Bertalanffy H, Seeger W: The dorsolateral, suboccipital, transcondylar approach to
the lower clivus and anterior portion of the cranio-cervical junction. Neurosurgery
29:815-821, 1991.
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3. Boulton MR, Cusimano MD: Foramen magnum meningiomas: Concepts, classifications,
and nuances. Neurosurg Focus 14:E10, 2003.
4. Bruneau M, George B. Foramen magnum meningiomas: detailed surgical approaches and
technical aspects at Lariboisire Hospital and review of the literature. Neurosurg Rev
31:19-32, 2008
5. Erkmen K, Pravdenkova S, Al-Mefty O: Surgical management of petroclival
meningiomas: Factors determining the choice of approach. Neurosurg Focus 19:E7, 2005
6. Hakuba A, Nishimura S, Jang BJ: A combined retroauricular and preauricular
transpetrosal-transtentorial approach to clivus meningiomas. Surg Neurol 30:108-116,
1988
7. House WF, De la Cruz A, Hitselberger WE: Surgery of the skull base: transcochlear
approach to the petrous apex and clivus. Otolaryngology 86:770-779, 1978
8. Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R: Expanded endonasal
approach: Fully endoscopic, completely transnasal approach to the middle third of
the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg
Focus 19:E6, 2005.
9. Kassam A, Snyderman CH, Mintz A, Gardner P, Carrau RL: Expanded endonasal
approach: The rostrocaudal axis-Part I: Crista galli to the sella turcica. Neurosurg
Focus 19:E3, 2005. Nakamura M, Roser F, Jacobs C, Vorkapic P, Samii M: Medial
sphenoid wing meningiomas: Clinical outcome and recurrence rate. Neurosurgery
58:626-639, 2006.
10. Kawase T, Shiobara R, Toya S: Anterior transpetrosal-transtentorial approach for
sphenopetroclival meningiomas: surgical method and results in 10 patients. Neurosurgery
28:869-876, 1991
11. Kondziolka D, Nathoo N, Flickinger JC, et al: Long-term results after radiosurgery
for benign intracranial tumors. Neurosurgery 53: 815-822, 2003
12. Lee JY, Kondziolka D, Flickinger JC, Lunsford LD. Radiosurgery for intracranial
meningiomas. Prog Neurol Surg 20:142-149, 2007
13. Malis LI: Suboccipital subtemporal approach to petroclival tumors, in Wilson CB (ed):
Neurosurgical Procedures: Personal Approaches to Classic Operations. Baltimore:
Williams & Wilkins, pp 41-51, 1992
14. Nakamura M, Roser F, Jacobs C, Vorkapic P, Samii M: Medial sphenoid wing
meningiomas: Clinical outcome and recurrence rate. Neurosurgery 58:626-639, 2006.
15. Nakamura M, Struck M, Roser F, Vorkapic P, Samii M: Olfactory groove meningiomas:
Clinical outcome and recurrence rates after tumor removal through the frontolateral and
bifrontal approach. Neurosurgery 60:844-852, 2007.
16. Samii M, Ammirati M: The combined supra-infratentorial presigmoid sinus avenue to
the petro-clival region. Surgical technique and clinical applications. Acta Neurochir 95:612, 1988
17. Samii M, Klekamp J, Carvalho G: Surgical results for meningiomas of the craniocervical
junction. Neurosurgery 39:1086-1095, 1996.
18. Samii M, Carvalho GA, Tatagiba M, et al: Surgical management of meningiomas
originating in Meckel's cave. Neurosurgery 41:767-775, 1997
19. Samii M, Tatagiba M, Carvalho GA: Retrosigmoid intradural suprameatal approach to
Meckel's cave and the middle fossa: surgical technique and outcome. J Neurosurg
92:235-241, 2000
20. Samii M, Gerganov MV: Surgery of extraaxial tumors of the skull base. Neurosurgery 62
(Suppl 3):1153-1166, 2008
21. Seoane E, Rhoton AL Jr: Suprameatal extension of the retrosigmoid approach:
microsurgical anatomy. Neurosurgery 44:553-560. 1999
22. Spetzler RF, Daspit CP, Pappas CT: The combined supra- and infratentorial approach
Principles
Principles and
and practice
practice of
of skull
skull base surgery
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269
for lesions of the petrous and clival regions: experience with 46 cases. J Neurosurg
76:588-599, 1992
23. Stippler M, Gardner PA, Snyderman CH, Carrau RL, Prevedello DM, Kassam AB.
Endoscopic endonasal approach for clival chordomas. Neurosurgery 64:268-277, 2009
24. Tedeschi H, Rhoton AL Jr: Lateral approaches to the petroclival region. Surg Neurol
41:180-216, 1994
25. Van Havenbergh T, Carvalho G, Tatagiba M, et al: Natural history of petroclival
meningiomas. Neurosurgery 52:55-64, 2003
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Basic principles of contemporary

skull base surgery:
microsurgical and endoscopic assisted
techniques.
Matteo de Notaris1,2 MD, PhD; Vita Stagno2,3 MD; Alberto PratsGalino2 MD, PhD; Domenico Solari3 MD; Enric Ferrer1 MD, PhD;
Joaquim Enseat1 MD, PhD.
1
Department of Neurosurgery, Hospital Clinic of Barcelona, Barcelona,
Spain.
2
Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine,
Universitat de Barcelona, Barcelona, Spain.
3
Department of Neurological Science, Division of Neurosurgery,
Universit degli Studi di Napoli Federico II, Naples, Italy.
The skull base represents the basis of the cranium upon which the brain rests; its
surface is complex and irregular due to the presence of foramina, depressions and
bone indentations that create several compartments. Neurovascular structures that are
crucial to the function and integrity of the entire central nervous system are contained,
and travel, therein.
It can be involved in a variety of lesions, neoplastic and/or inflammatory, vascular,
congenital and/or traumatic. The complexity of this anatomical region makes skull base
surgery a challenging discipline for neurosurgeons. For such reason, the management
of such lesions may require special techniques for their successful treatment.
It has to be said that cranial base surgery has rapidly developed since the beginning
of the past century when the surgery itself was still inadequate and incomplete, thus
attended by a high mortality and morbidity rate. The first pioneers of this discipline
were neurosurgeons, head and neck surgeons and otolaryngologists. From the first
decade of the 20th century, Harvey Cushing and Charles Harrison Frazier were some of
the surgeons that with audacity attempted the resection of lesion originating from the
base of the skull, considered inaccessible at that time (1, 2). Were indebted to them, as
through their efforts and mistakes they enabled the implementation and development
of contemporary cranial base surgery.
With the remarkable progress of computer hardware and software, modern
visualization tools such 3D operative microscopes and high definition endoscopes
have becoming a powerful assistive technology for neurosurgery. Technical progress
lead to the development of new devices and equipment such as advanced MRI and CT
neuroimaging techniques, frameless neuronavigation systems, pre-operative planning
software and intraoperative imaging tools have enhanced the safety of each intervention
and improved the outcome.
The new millennium was ushered in by a dramatic technological revolution and at
the same time we assisted to a progressive decline of the invasiveness of the surgical
Basic principles of contemporary skull base surgery: microsurgical and endoscopic assisted techniques.
271
procedure, with the ambition to decrease the morbidity and mortality rate and offer
a reasonable and significant chance for cure patients. Concerning such concept, it
must be remarked that modern minimally invasive surgery does not only imply that
the size of the craniotomy or craniectomy is reduced, it must be the perfect balance
between adequate maneuverability and simultaneously reduce the injury of normal
brain tissue.
In recent years, new concepts have been introduced in neurosurgery toward
minimally invasive and more tailored approaches and away from traditional cranial
base surgery dogmas. The advent of keyhole surgery and endoscopic techniques has
definitely confirmed the establishment of minimally invasive neurosurgery era. As a
natural consequence the concept of skull base surgery has evolved. Contemporary skull
base surgery tailors the site, the extent and the shape of the craniotomy to avoid large
bone openings and to reduce the needed for brain retraction in a refined balance.
Modern techniques have been compared for years to balance the need to minimize
brain retraction and maximize surgical exposure. The development of the contemporary
neurosurgical operative environment is driven principally by parallel evolution in
science and technology. Important tools including neuroendoscopic techniques as well
as neuronavigation and advanced intraoperative imaging, reflect the effort to reduce
morbidity and brain trauma, and to optimize the patient position, refine the size and
tailor the shape of the craniotomy.
Through new instruments as the endoscope, used as a sole visualizing tool or as a
complement to the classical microsurgical techniques, has allowed a superior closeup view of the vascular and neural structures and related pathology. Its application
to skull base surgery has demonstrated effective for the visualization and dissection
of blind corners between complex neurovascular structures. Indeed, during the last
decades, endoscopic assisted techniques have been widely adopted with success for
the treatment of several different lesions of the skull base, previously considered to be
almost inaccessible. Modern skull base centers must be equipped with microscopic
and endoscopic instrumentation and the planning of any skull base surgery should
consider the possibility to switch the microsurgical procedure to a pure or endoscopic
assisted surgery.
In this chapter we describe the basic principles for the main microsurgical and
endoscopic assisted approaches to the skull base in order to provide an overview of
its complex anatomy and to describe the technical steps of each specific approach.
Indications and surgical strategies will be also discussed.
Preoperative studies and surgical planning

The knowledge of surgical anatomy is imperative for complex neurosurgical
procedures in regions with vital structures nearby, as in skull base surgery.
In the field of neurosurgery, progress in neuroimaging studies such as high
resolution CT scans, MRI imaging studies and digital subtraction angiography data,
has certainly refined the visualization of anatomical structures within the brain and
the skull. On the other hand, the progress in computer technology and medical image
processing techniques has enabled stereoscopic display of anatomical structures from
272 Skull Base

computed imaging data. Indeed, three-dimensional (3D) imaging, which allows image
manipulation and surgical simulation on screen, has become an indispensable part of
the neurosurgical planning and training.
Our preoperative plan for skull base tumors provides 2 different procedures:
1. A virtual preliminary exploration of patients anatomy using the 3D reconstruction
modules supported by the OsiriX software (Osirix , Advanced open-Source PACS
Workstation DICOM viewer) in order to analyze the individual variability of the
anatomy. The Maximum Intensity Projection, the Volume rendering and the Surface
rendering were the 3D reconstruction modules are used to explore each case (Fig.
1A-B).
2. A dynamic 3D stereoscopic surgical planning using a medical visualization system
(Dextroscope, Volume Interaction) that, through the processing of multimodality
images, such as CT, MRI and PET/SPECT, allows building up 3D interactive
procedures with which to simulate surgical approaches. Such tool is composed of
a display platform and an interaction console with two hand-held electromagnetic
sensors that allow manipulation of the 3D data. At the end of the process, the
segmented objects (representing skin, tumor mass, vascular system, ventricular
cavities) are displayed by a combination of volume rendering and polygonal isosurfaces, ready to be manipulated (Fig. 1-C).
Both types of models have been previously utilized from recently published works
of our group concerning the anatomy of microscopic and endoscopic skull base
approaches.
Fig. 1 (A): MRI 3D reconstruction modules supported by OsiriX software (Osirix , Advanced openSource PACS Workstation DICOM viewer);(B): CT scan 3D reconstruction using the Volume rendering
Projection (C): 3D virtual reality simulation of the microsurgical clipping of an aneurysm using a
medical visualization system (Dextroscope, Volume Interaction)
The frontotemporal approach

The frontotemporal approach, popularized by Yasargil (3) for the treatment of
intracranial aneurysms, is still one of the most versatile and widely used approaches
in contemporary neurosurgery. It allows a wide exposure of the sellar, parasellar,
suprasellar and retrosellar areas and it has also been employed for a large number of
other applications, such as lesions of the sellar region, the cavernous sinus, and the
anterior and middle cranial fossa and as a basic step for more complex approaches to
the skull base. The widely recognized advantage of the frontotemporal craniotomy is
the enhanced exposure of deep neurovascular structures, which offer a shorter and
273
wider view of the surgical target. The immediate release of cerebrospinal fluid from
the basal cisterns and the early visualization of the neurovascular structures result in
a significant reduction in brain retraction and preservation of the normal vascular
anatomy. Furthermore, it allows the early identification of the homolateral internal
carotid artery and the anterior circle of Willis, thus providing an early proximal vascular
control.
Technique
The patient is placed in the supine position on the operating table with the legs
propped up on pillows. The head is rotated to the side contralateral to the approach
by approximately 15-20 and fixed to the Mayfield-Keys pin headrest, the definitive
position of the head will depend upon the type and location of the lesion to be treated.
The vertex of the head is then tilted down 1015 such that the malar eminence is
almost the highest point of the operative field. The skin incision is made 0.51 cm
anterior to the tragus advancing in a curvilinear shape through the hairlineforehead
interface until to reach approximately the midpupillary line (Fig.2A). When dissecting
the subcutaneous tissue the temporoparietal fascia or superficial temporal fascia come
into view. At this point the integrity of the superficial temporal artery should be
respected, as this vessel is essential to obtain a vascularized galeopericranial flap and for
extracranial-intracranial bypass surgery. The temporoparietal fascia can be divided in
two laminae with fat lying in between. Just beneath, a dense, tough and uniform tissue
forms the temporal fascia, also called deep temporal fascia. Cranial to the superior
temporal line, it is in continuity with the pericranium and caudally, over temporal
muscle, it splits into two layers approximately 23 cm above the zygomatic arch called
superficial and deep laminae, the superficial temporal fat pad is in between. The frontal
branch of the facial nerve lies just above superficial lamina, which cover such fat pad.
In order to avoid inadvertent damage to this nerve the incision over the temporalis
fascia should be performed close to the temporal line, parallel to the skin incision and
in a semilunar shape, in such a way to include both superficial and deep laminae. Once
the temporalis fascia is opened the temporal muscle dissection can be performed in
three different ways: interfascial, subfascial, or submuscular. We prefer the subfascial
dissection as, in our experience, it represents the safest approach to preserve the frontal
branch of the facial nerve (Fig.2B).
The keyhole is performed following Dandy description and is placed just above
the frontosphenoidal suture, below the superior temporal line and posterior to the
frontozygomatic suture. The craniotomy is directed toward the supraorbital notch to
approximately 2 cm above the orbital rim and continued downward in a curvilinear
fashion, over the parietal bone finishing over the sphenotemporal suture. Once the
bone flap is detached, the bone removal can extend by drilling the lesser wing of the
sphenoid, in order to optimize the basal trajectory to the skull base. The dural incision
is made in the usual semicircular fashion. A slight retraction of the frontal lobe allows
exposure of the carotid, chiasmatic and lamina terminalis cisterns (Fig.2C). With the
opening of the sylvian fissure, in a typical proximal to distal fashion, the entire circle of
Willis and its related arteries, optic nerves and chiasm, the pituitary stalk, the anterior
274 Skull Base

and posterior clinoid are exposed. Moreover, the opening of the Liliequists membrane
permits to gain access to the interpeduncular cistern with the basilar artery and its
branches come into view.
Endoscope assisted technique

The application of the endoscope assisted technique to classical transcranial
approaches was first described by Apuzzo et al. (4). A used side-viewing, angled-rod
lenses was used to assess the adequacy of the placement of aneurysm clips and to
assist in visualizing structures during pituitary surgery both for transsphenoidal and
subfrontal approaches. The endoscope lens can be guided through narrow corridors
and placed immediately adjacent to the region of interest, effectively bringing the
operator to the anatomy.
We believe that the use of an endoscope in conjunction with the operating microscope
can enhance the surgeons ability to visualize and control deep located neurovascular
structures.
In our experience, the endoscopic assisted technique has been found extremely
useful to complement the classic frontotemporal approach for the treatment of complex
intracranial aneurysms. As a matter of fact, the endoscope implements the visualization
of blind corners around the aneurysm and of perforating arteries, facilitating the
surgeon to accurately position the clip under microscopic view. Afterwards, the
endoscope can be introduced again to check the final surgical result and if necessary,
clip can be adjusted again under microscope. In selected cases the superior angle and
close-up view offered by the scope allows to realize a direct surgical clipping.
The endoscopic assisted microsurgical technique is a safe, minimally invasive and
effective alternatives to the traditional open cranial base approaches in selected supra
and parasellar tumors as well as for complex intracranial aneurysms (Fig. 2D).
Fig. 2 (A): The frontotemporal approach.
Position of the patient on the operating table
with the head fixed to the Mayfield-Keys pin
headrest; the skin incision is marked; (B):
Anatomic cadaveric dissection showing the
first phase of the procedure, with the temporalis
fascia kept in place and exposure of the
temporal muscle; noted how the pericranium
has been dissected from the skin flap; (C):
Intraoperative microscopic view showing
the optocarotid region (D):Intraoperative
endoscopic view demonstrating clipping of
an anterior communicating aneurysm.
P:pericranium; TF: temporalis fascia; TM: temporalis muscle; FB: frontal bone; ON: optic nerve; ICA:
internal carotid artery; OT: optic tract; AcoA: Anterior communicating artery; LT: lamina terminalis
275
The retrosigmoid approach

Krause developed the retrosigmoid approach at the beginning of the 20th century,
but only few decades later, with the introduction of intracapsular tumor removal by
Cushing, the surgery of the cerebellopontine angle become safer and less invasive. This
approach was ideated mainly for the treatment of acoustic neurinoma and other spaceoccupying lesions as meningiomas, epidermoids and chordomas, but it can be used
for a wide spectrum of pathological entities as trigeminal nevralgia, hemifacial spasm
and selected cases of vertebral artery and PICA aneurysms. Different variant of this
approach have been proposed and are currently used worldwide. The main advantage
of the retrosigmoid approach is related to the possibility to widely and safely access
lesions within the cerebellopontine angle region, the petrous bone and the petroclival
area.
More recently, the retrosigmoid-suprameatal approach popularized by Samii in 1982,
makes use of the simple and safe retrosigmoid craniotomy, combined with a resection
of the petrous apex and incision of the tentorium. Such approach has demonstrated the
effectiveness and safety to approach the cerebellopontine angle and allows for adequate
access and removal of any lesion developing in that area.
Furthermore, the advent of modern intraoperative neurophysiological monitoring
has reduced the procedure-related complications rate, very frequent in the beginning
of the 20th century, leading to a marked improvement of post-operative results.
Finally, with the diffusion of endoscopic skull base surgery, the idea to use the
endoscope for improve the visualization in the cerebellopontine angle area, either alone
or in combination with the microsurgical technique, has expanded, increasing the
safety of the procedure and further reducing the post-operative complications rate.
Surgical technique
The position of the patient in the operating table varies from the supine to the
semisitting or the park-bench position, with each one offering its own benefits and
disadvantages. We use a lateral decubitus or park bench position for the majority of
patients undergoing retrosigmoid surgery for posterior fossa tumors (Fig. 3A).
The skin incision is usually realized medially to the mastoid process in a slight curved
C shape; the muscular layer is incised in a longitudinal fashion and retracted until to
visualize the occipitomastoid area. The exposure of the occipitomastoid, the squamosal
and the lambdoid sutures is of utmost importance for exactly locates the sigmoid sinus.
The choice to perform a craniotomy rather than a craniectomy strictly depends from
the confidence of the surgeon with regards of its own technique. In both cases the
keyhole is placed inferomedially to the asterion, a dissector is used to dissect the dura
carefully from the overlying bone and to expose the edge of the sigmoid sinus. Usually
the craniotomy is placed at the transition of the transverse sinus into the sigmoid sinus,
but an extensive exposure of both sinuses should be avoided in order to prevent any
inadvertent laceration of such venous structures. The dura mater is incised, according
to Samiis principle, in a curvilinear fashion medial to the sigmoid and inferior to the
transverse sinus. Once the cerebellomedullary cistern is opened and the cerebellar
276 Skull Base

hemisphere is slight retracted, at this point, the neural and vascular structures of the
cerebellopontine area come into view (Fig. 3B). Depending on lesion location and size,
the intradural drilling of the suprameatal tubercle, the opening of the Meckels cave or
the incision of the tentorium can be performed in order to increase the width of the
surgical field.
Fig. 3 (A): The retrosigmoid approach.
Position of the patient on the operating
table with the head fixed to the MayfieldKeys pin headrest; the skin incision is
marked; (B): Intraoperative microscopic
intradural image. The cranial nerves
come into view after the cerebello
medullary cistern has been opened and
the cerebellum gently retracted.
V: trigeminal nerve; VII-VIII: facial and vestibulocochlear nerves; IX: glossopharyngeal nerve.

The use of the endoscope at early or late stage of a tumor removal can minimize the
approach related morbidity, as it offers a wide view over the whole cerebellopontine area
and the lateral surface of the brainstem without significant brain manipulation. In case
of neurovascular decompression the endoscope allows disclosing blind corners behind
critical structures and helping the surgeon to ensure the appropriate placement of the
selected graft (Teflon of other materials) implant between the neurovascular conflict.
Usually, in order to minimize the risk of damaging major neurovascular structures,
the endoscopic exploration follows natural corridors between the cranial nerves,
avoiding prolonged close-up view to such structures. Furthermore, constant saline
irrigation of the surgical field prevents thermal injury to the cranial nerves. Some
surgical corridors, as the one sited between the tentorium and trigeminal nerve and
the one between the V nerve and the VII-VIII complex are commonly encountered
(Fig.4A-C). Finally, the lower cranial can be exposed moving the endoscope caudally
and the hypoglossal nerves can be reached by angling the endoscope inferomedially
in the direction of the vertebrobasilar junction, passing through the corridor between
vagus superiorly and the accessory spinal nerves inferiorly.
Fig. 4 (A): Intraoperative endoscopic view during tumor removal of cerebello pontine epidermoid
tumor (B): preoperative and (C) postoperative T2-weighted fat suppressed MRI showing complete
removal of the lesion.
EP: epidermoid; T:tentorium V:fifth cranial nerve ; B:brainstem
277
The far lateral approach

When compared with others skull base approaches the routes to the ventrolateral
aspect of the brainstem and the cervicomedullary junction are considered pioneering,
probably due to the complex anatomy and the high morbidity of lesions developing or
extending within this area.
As a matter of fact the craniovertebral junction approach has been described for the
first time few decades ago and presented as a lateral variation of the classic unilateral
suboccipital approach. More recently, Bertalanffy et al reported their experience with
extended bone drilling towards the occipital condyle as a trial to obtain increased
angled surgical exposure (5-7). With the advent of skull base techniques and with
clear understanding of the anatomy of the foramen magnum region, lesion ventral
and ventrolateral to the foremen magnum can be accessed in most cases via far lateral
transcondylar approach. The advantage of the approach is that the procedure enhance
exposure of the brainstem while markedly reducing the need for brain retraction and the
risk of air embolisms using either a three-quarter prone or parch bench position(8)
Surgical technique
In the majority of cases, a modified park-bench position with a full lateral decubitus
and the head slightly rotaded cranially and flexed. The skin is incised in a slight curvilinear
or in a hockey-stick fashion behind the ear, in the retroauricular area (Fig.5A). The
insertion of the splenius capitis and sternocleidomastoid muscles is detached from the
superior nuchal line and the mastoid. The occipital artery is usually encountered at an
early stage of the procedure and should be adequately coagulated. The exposure of the
supracondylar fossa and the posterior edge of the foramen magnum proceeds with the
dissection along the deep suboccipital area until the exact location of C1 arch and its
transverse process are confirmed. The transverse process of C1 is an essential landmark
for confirming the location of the vertebral artery that can be isolated (Fig.5B). Usually
mobilization of the artery is not strictly recommended except for selected cases as
malign tumor with extension in the midbrain and low cervicomedullary region. The
definitive extension of the bone exposure depends on the location and the craniocaudal
growth pattern of the underlying lesion. The craniotomy has variable size and can be
extended from the sigmoid sinus up to the first cervical segments. Partial or complete
drilling of the occipital condyle can be helpful in augmenting the surgical exposure of
the anterior portion of the foramen magnum, while hemilaminectomy of C1 and/or C2
may become necessary to access cervicomedullary area (Fig.5C-D). The dura opening
is realized, depending on the extension of the craniotomy, in a C or Y fashion, taking
care to avoid excessive manipulation of the vertebral artery at its entrance point close
to the foramen magnum. The far lateral approach provides an adequate exposure and
viewing angle to the ventral and ventrolateral brainstem with minimal retraction of
important neurovascular structures.
278 Skull Base

Fig. 5 (A): Far lateral approach. Position of the
patient on the operating table with the head fixed
to the Mayfield-Keys pin headrest; the skin incision
is marked; (B): Intraoperative image showing the
exposure of the vertebral artery and the dura mater
over the craniocervical junction;(C): Osirix 3D
Volume Rendering reconstruction showing the
shape and the boundaries of the craniotomy; (D)
Anatomic cadaveric image showing the extent of
the craniotomy; noted the hemilaminectomy of
C1.
VA: vertebral artery; dm: dura mater; Hc: hypoglossal canal; C1: atlas

During the last years continuous advancements in endoscopic skull base surgery
have ported great advantages to the surgery of craniovertebral junction. The close-up
and angled view offered by the scope has been valuable during the resection of both
extradural and intradural lesions, so that endoscopic assisted techniques are nowadays
considered fundamental while approaching lesions within this area.
Using the natural surgical corridors between the lower cranial nerves and the first
cervical roots it is possible to gain a paramount view over the most anterior portion
of the petroclival area and the cervicomedullary region, thus limiting the amount of
drilling of the occipital condyle.
In selected cases an extended endoscopic endonasal approach can be complementary
to access lesion extended ventrally to the lower cranial nerves. In such cases, a combined
microscopic far lateral approach/transclival endoscopic endonasal approach(9, 10) in a
single or in two stages can be used to achieve a complete exposure of the lower cerebello
pontine angle region. (Fig.6A-B)
Fig. 6 Illustrative case showing a clivalchordoma
extending into the craniocervical junction (A):
Preoperative and (B) Postoperative T1 postcontrast high resolution MRI, axial sequences,
showing the combined microscopic far lateral
approach/transclival
endoscopic
endonasal
approach used to gain access to the entire lesion.
Subfrontal approach
Sir.Victor Horsley performed the first subfrontal approach to operate a pituitary
adenoma in 1889(1). Since then many advancements have been made in the development
279
of this approach(3, 11, 12).

It offers a wide exposure over the anterior cranial base with a wide overview of the
cribriform plate, sellar, suprasellar, and parasellar areas. Using such route it is possible
to gain an excellent midline orientation in order to expose the main neurovascular
structures: the cavernous sinus, optic and olfactory nerves and internal carotid
arteries.
Surgical technique
Patient is placed supine with head slightly elevated 20 degrees for frontal lobes to
fall away from the anterior skull baseand kept in neutral position in Mayfield clamp.
A bicoronal skin incision is realized starting 1 cm anterior to the tragus and extending
behind the hairline, in a curvilinear fashion, to the opposite side. The flap is then elevated
in a single skin-aponeurosis layer and retracts with temporary fishhooks (Fig.7A). As
the dissection is carried anteriorly, care is taken to preserve the supraorbital nerve. A
wide pericranium flap can be easily obtained, at any time during the procedure, for
subsequent skull base repair. A bifrontal craniotomy upper the orbital rims is generally
performed, with the burr hole placed at the Mc-Cartys point bilaterally, just below the
superior orbital ridge. One or two more burr holes are placed close to the midline, in
such a way to avoid superior sagittal sinus injury (Fig.7B).
The frontal sinus, whenever opened, is repaired being covered with the pericranium
flap, after the mucosa is completely removed and the cavity is carefully packed with
muscle. Two separate dura opening are realized on both sides, with the base of the
opening being at the orbital roof. On the midline, two ligatures are passed through the
falx in such way to safely cut the sinus on its anterior margin along with the falx until
its inferior border. Finally, in order to get access to the anterior skull base region the
frontal lobes are gently retracted, thus permitting the visualization of the suprasellar
area (Fig.7C). The subfrontal bilateral approach allows exposure of the whole surface of
the anterior cranial base, offering the best view over the suprachiasmatic area. The optic
nerves, the chiasm, the internal carotid artery, its bifurcation and the anterior Circle of
Willis are under symmetric panoramic view.
Fig. 7 (A): Subfrontal approach. Intraoperative image showing the skin-aponeurosis flap elevated and
retracted with temporary fish hooks.(B): Intraoperative image showing the bifrontal craniotomy with
the burr hole placed at the Mc-Cartys point bilaterally and one close to the midline to avoid superior
sagittal sinus injury;(C): Illustrative anatomic image showing the main neurovascular structures
within the suprasellar region.
PC: posterior clinoid; ON: optic nerve; Pg: pituitary gland; ps: pituitary stalk; Ch: optic chiasm; ICA:
internal carotid artery; A1: precomunicant segment of the anterior cerebral artery.
280 Skull Base

The endoscopic-assisted techniques have been developed to extirpate selected
tumors that mainly involve the sphenoidal planum and tuberculum sellae areas. In
the majority of cases a 30 or 45 degree endoscope is used as an aid to excise tumor
remnants in proximity of neurovascular structures such as the optic nerves, the
pitutary stalk and anterior cerebral arteries. With the endoscope, a panoramic view
of the seller and suprasellar area is obtained. In selected cases, such as giant anterior
skull base meningiomas or sinonasal tumors with large intracranial extension a
combined microscopic subfrontal (Fig.8A) and endoscopic endonasal transcribriform
approach (Fig.8B) can be performed to optimize tumor resection (Fig.8C-D). The
main advantage of this approach is to combine the minimally invasive elements of
the endonasal approach with the 3-dimensional view gained with the microscope.
Moreover, a combined transcranial/endonasal procedure adds the significant advantage
of a wide exposure of the intradural component of the lesion, especially over its lateral
extension, together with a more accurate reconstruction of the bone and dural defects
of the anteriorskull base (13).
Fig. 8 Illustrative case showing the removal of a sinonasal tumor with large intracranial extension
through a combined microscopic subfrontal and endoscopic endonasal transcribriform approach.
(A): Intraoperative microscopic subfrontal approach picture showing the drilling via the nose of the
cribriform plate; (B) Intraoperative endoscopic endonasal approach picture demonstrating the drilling
of the lateral part of cribriform plate from a subfrontal approach; preoperative (C) and postoperative
(D) T1-weighted coronal brain MRI showing the tumor resection.
1. Donald P. History of skull base surgery. In: Donald P, editor. Surgery of the skull base.
Philadelphia: Lippinicott-Raven; 1998. p. 313.
2. Maroon JC. Skull base surgery: past, present, and future trends. Neurosurg Focus. 2005
Jul 15;19(1):E1.
3. Yasargil MG. Microneurosurgery, Vol.1. Stuttgart: Georg Thieme Verlag; 1984.
4. Apuzzo ML, Heifetz MD, Weiss MH, Kurze T. Neurosurgical endoscopy using the
side-viewing telescope. J Neurosurg. 1977 Mar;46(3):398-400.
281
5. Bertalanffy H, Gilsbach JM, Mayfrank L, Klein HM, Kawase T, Seeger W. Microsurgical

management of ventral and ventrolateral foramen magnum meningiomas. Acta
Neurochir Suppl. 1996;65:82-5.
6. Bertalanffy H, Seeger W. The dorsolateral, suboccipital, transcondylar approach to the
lower clivus and anterior portion of the craniocervical junction. Neurosurgery. 1991
Dec;29(6):815-21.
7. Kawashima M, Tanriover N, Rhoton AL, Jr., Ulm AJ, Matsushima 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.
2003 Sep;53(3):662-74; discussion 74-5.
8. Heros RC. Lateral suboccipital approach for vertebral and vertebrobasilar artery
lesions. J Neurosurg. 1986 Apr;64(4):559-62.
9. de Notaris M, Cavallo LM, Prats-Galino A, Esposito I, Benet A, Poblete J, et al.
Endoscopic endonasal transclival approach and retrosigmoid approach to the clival
and petroclival regions. Neurosurgery. 2009 Dec;65(6 Suppl):42-50; discussion -2.
10. Morera VA, Fernandez-Miranda JC, Prevedello DM, Madhok R, Barges-Coll J, Gardner
P, et al. Far-medial expanded endonasal approach to the inferior third of the clivus:
the transcondylar and transjugular tubercle approaches. Neurosurgery. Jun;66(6 Suppl
Operative):211-9; discussion 9-20.
11. Aryan HE, Ozgur BM, Jandial R, Levy ML. Subfrontal transbasal approach and technique
for resection of craniopharyngioma. Neurosurg Focus. 2005 Jun 15;18(6A):E10.
12. Arbit A. Combined craniofacial resection for anterior skull base tumors.
13. Galassi E, Pasquini E, Frank G, Marucci G. Combined endoscopy-assisted cranionasal
approach for resection of infantile myofibromatosis of the ethmoid and anterior skull
base. Case report. J Neurosurg Pediatr. 2008 Jul;2(1):58-62.
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Microsurgical treatment of Olfactory

Groove Meningiomas
ROSSANA ROMANI, MD, MARTIN LEHECKA, MD, PhD,
MIKA NIEMEL, MD, PhD, and JUHA HERNESNIEMI, MD, PhD
Department of Neurosurgery, Helsinki University Central Hospital, 00260 Helsinki,
Finland
Key words: olfactory groove, meningioma, lateral supraorbital approach, pterional
approach bifrontal approach, fronto-orbital approach
Introduction
Different surgical approaches to remove olfactory groove meningioma have been
described (3-5, 7, 10, 16-22, 24) (Table 1). In our experience olfactory groove
meningioma can be safely removed via a small lateral supraorbital (LSO) approach with
low co-morbidity, and even the olfactory function can be preserved, depending on the
size of the tumor. This small approach does not lead to significant number of recurrences,
provided that the tumor does not infiltrate the ethmoidal sinuses.
Neuroradiological examinations
Computed tomography (CT) and magnetic resonance imaging (MRI) are the
examinations that should be done before all OGM surgery. The MRI can be completed
by angiographic sequence (MRA) to evaluate the tumor's vascular supply and relation to
the anterior cerebral arteries (ACAs). Digital subtraction angiography (DSA) is not
necessary as well as preoperative embolization of the tumor feeders because the majority
OGMs vascular support comes through the anterior and posterior ethmoidal arteries
(AEAs and PEAs), which originate from the ophthalmic artery (OA) (6, 14)and are
difficult to embolize. The preoperative radiological examinations have to consider
tumor size, lateralization, possible calcifications, signs of hyperostosis, ethmoidal and sellar
infiltration, involvement of ACAs, of optic chiasm and brain edema. An immediate
postoperative CT scan should be performed to exclude surgical complications and an
early postoperative MRI with gadolinium enhancement can be done when a tumor
remnant is suspected and to follow-up the patient.
Surgical technique
Lateral supraorbital approach (LSO)
Position of the patient: 1) head fixed to the head frame 2) elevated clearly above the cardiac
level, 3) rotated 20 -30 towards the opposite side, 4) tilted laterally for optimal
visualization of the attachments of the OGM, 5) the neck of the patient is slightly
Microsurgical
Microsurgical treatment of Olfactory Groove Meningiomas
Table 1 Some of the major contibutions to surgery of OGM
155
283
156 Neuro-oncology
284
Skull Base
flexed to obtain a better view of the anterior part of the anterior fossa (Fig.1).
Skin and muscle incision: following an oblique frontotemporal skin incision (Fig.2),
the muscle is cutted in one layer with the skin and retracted frontally with spring
hooks. The superior orbital rim and the anterior zygomatic arch are exposed. The
upper part of the temporal muscle is split and retracted towards the zygomatic arch.
Craniotomy: a single burr hole is placed under the temporal line of the bone, i.e. the
superior insertion of the temporal muscle. The bone flap is 3 X 3 cm and it is detached
at the basal part by lifting (Fig.3). The dura is incised curvilinearly with the base
sphenoidally and elevated by multiple stitches. From this point onwards, all surgery is
performed under the operating microscope, including skin closure.
Fig. 1 Head position in LSO approach

elevated clearly above the cardiac level and
rotated 20 -30 towards the opposite side.
Fig. 2 Skin incision in performing a left LSO approach.
Fig. 3 One burr hole and the craniotomy in a

left LSO approach
Microsurgical
157
285
Removal of OGM through LSO

Slack brain is achieved by both neuroanesthesia and intraoperative release of
cerebrospinal fluid (CSF). The floor of the anterior skull base is followed towards the
ipsilateral optic nerve and carotid artery, and CSF is released from the basal cisterns. The
opening of the sylvian fissure is not necessary but if it needs can be easily performed
through the LSO approach, as our experience with MCA or anterior circulation
aneurysms shows (11-13). After opening the basal cisterns, with slack brain and more
space under the frontal lobe, dissection is directed to the medial dural attachments of the
tumor. The goal is to interrupt the major arterial supply to the tumor before further
dissection to ensure minimal intraoperative blood loss. Devascularization of the tumor
is performed with bipolar coagulation of the whole dural attachment, taking care to
preserve the olfactory tractfunction. In fact, coagulation of the AEAs and PEAs is
necessary at the beginning of OGM removal, and this can easily cause ischemic damage
to the olfactory tract (9).
Small (< 3 cm) and medium-sized (3- 6 cm) OGMs
In small and medium sized OGM depending on the tumor's consistency, and
attachments, preserving both olfactory tracts can be possible. In our experience the
olfactory tract ipsilateral to the tumor is identified and dissected free from the tumor mass
in small and sometimes in medium-sized tumors (< 6 cm). The tumor is debulked with
suction and a high-power bipolar (Malis CMCIII Codman, Synergetics, Inc., values
50-60). The water dissection technique is very effective in dissecting meningiomas, and
we use it routinely (15). In general, it is more difficult to dissect the contralateral than the
ipsilateral olfactory tract. However, usually at least one olfactory tract is already
compromised by the tumor, and the slightest manipulation can abolish its function.
Large OGMs (> 6 cm)
The olfactory tracts are usually compressed or destroyed by a large tumor (> 6 cm),
and there is less room for dissection due to brain edema. If the basal cisterns cannot be
reached to release CSF, the tumor is debulked with high power coagulation.
Devascularization of the tumor as early as possible is especially important in large
OGMs. An ultrasonic aspirator is seldom used, as the combined repetitive movement of
suction and bipolar forceps achieves the same result with less bleeding. Mechanical
retractors are not used to prevent long-lasting compression of the already edematous
frontal lobe brain. As the debulking progresses, the remaining tumor is brought down
away from the brain tissue towards the cribriform plate. Monopolar coagulation is
seldom used since the current spreads much wider than the bipolar coagulation, with the
risk of additional damage to adjacent neural structures.
Attachments to ACAs and to the optic chiasm
Large OGM can be attached in the posterosuperior part to the ACAs. Sharp dissection
is used to detach both ACAs from the tumor (Fig. 4A, 4B). All arterial branches coming
from the ACAs should be preserved, but some of the small branches supply the tumor
directly and must be coagulated (Fig. 4C). The posterior part of the tumor can be
attached to the supraclinoid carotid arteries and the optic nerves or chiasm. High
magnification, sharp bipolar forceps (Malis +20, +25), and sharp dissection are necessary
when working in this area, with the aim of preserving all of the small perforators,
including the blood supply of the chiasm.
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Fig. 4 Large OGM operated on through right LSO. Axial (A) and sagittal (B) views of T1-contrasted
MRI showing the posterior attachment of the tumor to the ACA (white arrows); C: Coronal T2-sequence
showing the small perforator coming from the ACA to the tumor (dark arrows). D: Axial view of T1contrasted MRI, 3 months after tumor removal.
Hyperostosis
Once the tumor has been completely removed, the dura of the anterior skull base is
carefully coagulated with bipolar forceps (Simpson grade 2). In patients with long life
expectancy, the dura near the origin of the tumor is stripped off with either monopolar
or knife modality, and the hyperostotic bone is drilled away (Simpson 1) (1).
Infiltration of ethmoid sinuses
In patients with a good prognosis and long life expectancy, the tumor infiltrating the
ethmoid sinuses must be removed. This requires a larger bone flap, resection of the crista
galli, and partial transection of the basal portion of the anterior margin of the falx. A highspeed diamond drill is used to open the ethmoid sinuses. Unless the bony window is
sufficiently large, some tumor may go unnoticed behind the corner. The bony defect can
be closed with the help of pericranial tissue, autologous fat, muscle, or fascia grafts. Fibrin
glue, used widely over the last 20 years, has proved to be an important adjunct in
preventing postoperative CSF leakage.
Differences between LSO, pterional, bifrontal, frontoorbital approaches

The pterional approach (23-25) has the advantage to spare the SSS and frontal
cortical veins, to avoid compressing the frontal lobes, and simultaneously to allow the
surgeon to visualize the anterior circulation, the basal feeders, and the optic nerve and
chiasm. This approach does not allow preservation of the contralateral olfactory nerve
(6, 10). The middle fossa extension of the pterional approach is unnecessary in removal
OGM and only the frontolateral part of the approach is needed. The LSO approach has
been used by the senior author (J.H.) in 66 consecutive OGM patients operated on since
1997. In this approach, the sylvian fissure remains at the border of the craniotomy
and can be easily opened if necessary, as our experience with MCA and other anterior
circulation even posterior circulation aneurysms shows (11-13). The LSO approach
provides the same advantages as the classic pterional approach, but is less traumatic and
faster. CSF release after opening the basal cisterns gives space to visualize the necessary
neurovascular structures. In large meningiomas, debulking of the tumor enables
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dissection of the A2 branches and the posterior part of the tumor.

Compared with the bifrontal approach, the LSO approach ha less exposure of the
frontal lobes with less surgical manipulation or frontal lobe retraction, the anterior
third of the SSS is preserved with the frontal draining veins with less risk of frontal
infarction and increased edema; only rarely the frontal sinus can be opened, requiring
much less reconstruction at the end of the procedure. In a recent surgical study, about
OGM, comparing a simple frontolateral approach (very similar to our LSO approach)
with the bifrontal approach, three patients in the bifrontal group died due to
postoperative brain edema. No deaths occurred in the frontolateral group. The authors
concluded that the anterior third of the SSS should be preserved during OGM surgery,
and this is better achieved with the frontolateral approach (16). Al-Mefty and Babu
recommended a unilateral frontal craniotomy with orbital osteotomy to prevent
bifrontal retraction, leading to possible mental changes (1, 2). A recent anatomical
study compares the surgical exposure of the pterional, orbitozygomatic, and
minisupraorbital approaches. The authors conclude that the minisupraorbital approach
with removal of the orbital rim gives a similar surgical view as the pterional and
orbitozygomatic approaches (8). In our experience, inclusion of orbital osteotomy is not
necessary or beneficial when the LSO approach is used to remove OGMs.
Surgical complications
Postoperative CSF leakage
CSF leakage can happen especially in those tumors infiltrating the ethmoid sinus. Our
policy is first to use the lumbar drainage for a few days and if the fistula still persists we
perform a recraniotomy with plastic of the skull base by using autologous fat or fascia lata.
Six of our 66 patients (9%) developed CSF leakage from the nose, three of them with
tumor infiltration into the ethmoid sinuses. Four of the six patients were treated with
lumbar drainage for a few days. The other two patients required a fascia lata graft.
Hydrocephalus
This is a rare surgical complication and we had only two patients with postoperative
hydrocephalus, one received a ventriculoperitoneal shunt.
Postoperative hematoma
Especially in large meningioma a postoperative hematoma can happen. We had only
one patient with large meningioma who presented postoperative hematoma in the
resection cavity requiring evacuation.
Clinical complications
Anosmia
New postoperative anosmia unrelated , in our experience, with the tumor size is a
frequent clinical complication after OGM surgery. New postoperative anosmia appeared
in six patients (9%). All six tumors were of either hard (n=3) or medium (n=3)
consistency. Three of these six patients had tumor infiltration into the ethmoid sinuses.
Olfactory function improved in two patients, both of them with a medium-sized tumor
extending more to the right side.
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Visual deficit
Postoperative visual deficit is in our experience unrelated to the tumor consistency and
size. In our experience five patients developed new deficits. Two were large, soft tumors.
Of the other three, one was small, one was medium, and one was large; all had a
medium consistency. No patients with a hard tumor developed new postoperative
visual deficits. Of the 14 patients with a preoperative visual deficit, three improved
after surgery and 11 remained unchanged.
Surgical mortality
No surgery-related mortalities occurred. Four patients died of unrelated cause during
the follow-up.
Conclusion
We believe that all size of OGM can be safely removed by using a small LSO approach.
REFERENCES
1. Al-Mefty O : Tuberculum sella and olfactory groove meningiomas. In Sekhar LN,Janecka
IP:Surgery of Cranial Base Tumors New York:Raven Press 1992.
2. Babu R, Barton A, Kasoff SS: Resection of olfactory groove meningiomas: technical note
revisited. Surg Neurol 44:567-572, 1995.
3. Bakay L,Cares HL: Olfactory meningiomas.Report on a series of twenty-five cases. Acta
Neurochir 26:1-12, 1972.
4. Bassiouni H, Asgari S, Stolke D: Olfactory groove meningiomas: functional outcome in
a series treated microsurgically. Acta Neurochir (Wien) 149:109-121, 2007.
5. Cushing H,Eisenhardt L: Meningiomas: Their classification, regional behaviour, life
hystory, and surgical end results. Springfield, IL, Charles C Thomas 1938.
6. Dare AO, Balos LL, Grand W: Olfaction preservation in anterior cranial base approaches:
an anatomic study. Neurosurgery 48:1142-5; discussion 1145-6, 2001.
7. El Gindi S : Olfactory groove meningioma: surgical techniques and pitfalls. Surg
Neurol 54:415-417, 2000.
8. Figueiredo EG, Deshmukh V, Nakaji P, Deshmukh P, Crusius MU, Crawford N,
Spetzler RF, Preul MC: An anatomical evaluation of the mini-supraorbital approach and
comparison with standard craniotomies. Neurosurgery 59:ONS212-20; discussion
ONS220, 2006.
9. Gerber M, Vishteh AG, Spetzler RF: Return of olfaction after gross total resection of an
olfactory groove meningioma: case report. Skull Base Surg 8:229-231, 1998.
10. Hassler W,Zentner J: Pterional approach for surgical treatment of olfactory groove
meningiomas. Neurosurgery 25:942-5; discussion 945-7, 1989.
11. Hernesniemi J, Romani R, Niemela M: Skull base and aneurysm surgery. Surg Neurol
30-31, 2009.
12. Hernesniemi J, Ishii K, Niemela M, Smrcka M, Kivipelto L, Fujiki M, Shen H: Lateral
supraorbital approach as an alternative to the classical pterional approach. Acta
Neurochir Suppl 94:17-21, 2005.
13. Hernesniemi J, Dashti R, Lehecka M, Niemela M, Rinne J, Lehto H, Ronkainen A,
Koivisto T, Jaaskelainen JE: Microneurosurgical management of anterior communicating
artery aneurysms. Surg Neurol 70:8-28; discussion 29, 2008.
14. Lang J: Clinical anatomy of approaches. Bifrontal and frontolateral approach. Lang J
(ed): Skull Base and Related Structures. Stuttgart: Schattauer, 1995, pp 97-112.
Microsurgical
161
289
15. Nagy L, Ishii K, Karatas A, Shen H, Vajda J, Niemela M, Jaaskelainen J, Hernesniemi J,

Toth S: Water dissection technique of Toth for opening neurosurgical cleavage planes.
Surg Neurol 65:38-41; discussion 41, 2006.
16. Nakamura M, Struck M, Roser F, Vorkapic P, Samii M: Olfactory groove meningiomas:
clinical outcome and recurrence rates after tumor removal through the frontolateral and
bifrontal approach. Neurosurgery 60:844-52; discussion 844-52, 2007.
17. Ojemann RG : Meningiomas:Clinical features and surgical management. In Wilkins
RH,Rengachary SS:Neurosurgery New York:McGraw-Hill 1985.
18. Olivecrona H,Urban H: Uber Meningeome der Siebbeinplatte. Brun's Beitr Klin Chir
161:224-253, 1935.
19. Solero CL, Giombini S, Morello G: Suprasellar and olfactory meningiomas. Report on
a series of 153 personal cases. Acta Neurochir (Wien) 67:181-194, 1983.
20. Spektor S, Valarezo J, Fliss DM, Gil Z, Cohen J, Goldman J, Umansky F: Olfactory
groove meningiomas from neurosurgical and ear, nose, and throat perspectives:
approaches, techniques, and outcomes. Neurosurgery 57:268-80; discussion 268-80, 2005.
21. Tonnis W: Zur Operation der Meningeome der Siebbeinplatte. Zentralblatt fur
Neurochir 1:1-7, 1938.
22. Turazzi S, Cristofori L, Gambin R, Bricolo A: The pterional approach for the
microsurgical removal of olfactory groove meningiomas. Neurosurgery 45:821-5;
discussion 825-6, 1999.
23. Yasargil MG: Surgical Approaches. Yasargil MG (ed): Microneurosurgery.
Microneurosurgery of CNS Tumors. New York: George Thieme Verlag Stuttgart, 1996,
pp 29-68.
24. Yasargil MG: Meningiomas. Yasargil MG (ed): Microneurosurgery. Microneurosurgery
of CNS Tumors. New York: Thieme, 1996, pp 134-185.
25. Yasargil MG: General Operative Techniques. Yasargil MG (ed): Microneurosurgery. New
York: Thieme-Stratton, 1984, pp 208-233.
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Surgical Treatment of Complex Tumors

of The Anterior Skull Base: The Transbasal
Extended Approach
MIGUEL A. ARRAEZ
Chairman, Dept. of Neurosurgery Carlos Haya University Hospital. Malaga. Spain
Key words: Anterior fossa, Skull base surgery, Transabasal extended approach
INTRODUCTION
The anterior skull base is a very difficult and challenging field for the neurosurgeon.
It comprises different anatomical compartments and structures (bone, brain, meningeal
layers, vessels, cranial and peripheral nerves, nasal cavity and paranasal sinuses, orbit).
Tumors arising at the anterior skull base may growth in a very capricious manner
invading the surrounding structures. The skull base surgery philosophy (cranial and facial
osteotomies) is extremely useful to expose and resect those lesions insofar as these
approaches allow for the adequate and simultaneous exposure of the different
compartments. After resection, the skull base reconstruction is of outstanding importance
to restore anatomy, function and to avoid complications.
ANATOMICAL CONSIDERATIONS
The proper knowledge of the relevant anatomy of the anterior skull base is very
important. The frontal, sphenoidal and ethmoidal bones compose the anterior fossa floor.
The anterior midbase corridor is located between both orbits, and is a very frequent origin
of skull base neoplasms arising at the anterior fossa and upper nasal cavity. The anterior
midbase is very close to nasal/paranasal contaminated cavities: Sphenoid sinus, ethmoid
sinuses and frontal sinus. The postero-lateral aspect of the anterior midbase is in close
vicinity with the optic canals and optic nerves.
The orbit is a very important and eloquent structure at the anterior skull base.
Sometimes is distorted and invaded by the lesion. The removal of the tumor must be
followed by reconstruction of the orbital walls (usually medial wall and/or orbital roof)
to avoid cosmetic problems and diplopia. The orbital apex is another area of great
concern, as sometimes is also involved. Optic nerve, carotid artery and oculomotor nerves
can be affected. In some cases of mailgnacy, orbital exenteration must be carried out when
the orbital content is involved. The optic nerve is very frequently affected by tumors at
the anterior skull base. It can be compressed at the intradural, intracanal or intraorbital
segment.
The carotid artery and cavernous sinus are the lateral limits of the transfrontal
Surgical
The Transbasal Extended Approach
Surgical Treatment
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midline approaches. The carotid artery can be damaged during surgery at the posterior
vertical portion (C5 segment). Inferiorly, hypoglossal nerves are the lateral limits.
The sellar region can be also approached trough the subfrontal/transfrontal route,
although we have to take into account that the posterior clinoids are a blind area for this
approach. The body of the sphenoidal bone can be reached until the lower third and
anterior foramen magnum. The clival approach requires careful frontal lobe retraction.
The anterior skull base bone is bearing both frontal lobes. The duramater is adherent
to the bone, and very thin at the cribiform plate, anterior clinoids and lesser sphenoid
wing. These areas are very difficult to be sutured after tumoral resection, and are very
prone to postoperative fistula. The inferior aspects of both frontal lobes (rinencephalon
and olfactory nerves) are in close contact with the anterior skull base. The tumor
usually damages the olfactory anatomy because of cribiform plate involvement.
DIAGNOSTIC EVALUATION OF THE ANTERIOR SKULL BASE

NEOPLASMS
The diagnostic preoperative evaluation is of paramount importance to define the
anatomical extension of the tumor. Only after careful preoperative evaluation can we
adequately choose the most appropriate approach and also plan the reconstruction of the
anterior skull base. This is especially important in reoperation cases.
Magnetic Resonance Image with and without gadolinium is necessary to assess the
extent and neuroradiological characteristics of the lesion. It helps to guess the degree of
vascularization and outline the invasion of brain parenchyma, orbit and nasal/paranasal
structures. CT scan with bone algorithm (axial and coronal images) is of great help to
establish the involvement of the bone. The current equipments provide really useful 3D
reconstructions that incorporates tumor, bony and vascular anatomy.
Angiography must be done if high vascularization is suspected. If so, preoperative
embolization must be tried. The vascularization of the tributaries from external carotid
artery can be embolized, unlike the component from the internal carotid artery and its
branches. Intraoperative direct embolization is sometimes done, but the risk increases as
the vascularization comes from the internal carotid circulation.
SURGICAL APPROACHES: THE TRANSBASAL-TRANSFRONTAL

EXTENDED APPROACHES
The current standard approach to remove complex lesions at the anterior skull base
includes a bifrontal craniotomy with the addition of a supraorbital rim bilateral
osteotomy. This philosophy has received many denominations (transbasal, extended
subfrontal, frontal transbasal, standard subfrontal). Transbasal extended approach is a
term that can give honor to the initial description (Derme, transbasal approach)
incorporating also the concept of the extended added osteotomy (Shekhar, Sen). From
this concept of bifrontal craniotomy and orbital rim osteotomy, different approaches can
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be devised in a modular fashion.
The transbasal extended approach can provide adequate exposure for lesions growing
at the anterior midbase with involvement of spheno-ethmoidal bone and adjacent
dural/intradural subfrontal region. The paranasal sinuses and upper nasal cavity can be
also reached. Both orbits are easily exposed. The clivus can be approached even to the
lower third (anterior foramen magnum) with the lateral limits of the cavernous sinus and
hypoglossal nerves (lateral and inferiorly). When the lesion is beyond the above
mentioned lateral limits, a modified procedure (antero-lateral resection) is needed.
When the tumor is malignant and is also affecting the maxillary region, a combined
transfacial approach (craniofacial resection) is indicated, that can even incorporate
orbital structures amenable for resection.
SURGICAL STEPS
Positioning
The patient is positioned in supine position, with the head neutral and slightly
extended to ease the retraction of frontal lobes. Spinal drainage, manitol and
dexametasone are used to relax the frontal lobes.
Scalp and soft tissue

A bifrontal-coronal incision far behind the hairline is done, reaching both preauricular
creases. It precludes from unaesthetic scar visible at the forhead and provides exposure
to get a very long and broad based pericraneal flap for reconstruction of the skull base
and/or dural plane (Figure 1). The temporal fascia must be preserved, and also the
supratrochear and supraorbital arteries at the orbital rim, as they supply the pericraneal
and miofascial frontal flap. The supraorbital nerve and artery are not damaged if the
supraorbital foramina is opened carefully (small punch or chisel). The detachment of the
soft tissue must expose the glabelar region and orbital rim.
Fig. 1 Exposition of the

cranial vault after scalp
incision (A) beyond the
hairline to avoid frontal
scars. This exposition also
provides a broad pericraneal
flap (B).
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Craniotomy and skull base osteotomies

A bifrontal craniotomy is carried out. Usually five burr holes (Figure 2) are needed
(two at both sides of the sagital sinus, one in midline besides the frontal sinus and one
lateral burr hole at each side behind the frontozygomatic suture, that is hidden under the
temporal muscle). The release of CSF (spinal drainage) helps to gentle retract both frontal
lobes. Both orbital roofs are exposed after careful detachment of the duramater. The
periorbital layer is dissected from the medial and superior orbital walls. The anterior base
is cut accordingly with the extension of the tumor. If the olfaction is yet preserved, an
osteotomy of the cribiform plate including the adjacent nasal mucosa can avoid
postoperative anosmia. If already present, both olfactory rootlets and duramater are cut
at the level of the anterior ethmoid, and the duramater sutured. The biorbital rim
ostetomy is done with a different extension and anatomical variation according to the
need for exposure of the lesion (Figure 3).
Fig. 2 A: Bifrontal craniotomy and fronto-orbital osteotomy. The bifrontal craniotomy is

done with the aid of five burr holes: two at both sides of the sagital sinus, one in midline
besides the frontal sinus and one lateral burr hole at each side behind the zygomatic
process of the frontal bone. B: Transillumination through the anterior fossa (left orbit)
showing the weak areas where the osteotomy can be more easily done at the roof of the orbit.
Fig. 3 Lines of cutting at

the anterior skull base to
carry out the fronto-orbital
osteotomy. Superior (A)
and anterior (B) view. In
C we can see the orbital
bandeau obtained after
cutting through the white
line of image A. In D we
can see a fronto-ethmoidorbital flap after cutting
through the yellow line of
osteotomy.
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Tumor resection
The tumor is resected according to the anatomical involvement, extension and
biological characteristics. The midbase corridor is easily exposed and removed. Malignant
tumors can be excised en bloc if possible. The sphenoidal and ethmoidal extension can
be removed, as well as the nasal invasion (Figures 4 and 5). Optic nerve compression is
a frequent finding in anterior skull base neoplasms (Figures 6 and 7). The optic canals
must be skeletonized following any bony landmark not distorted by the tumor (i.e,
entering the sphenoid sinus or following the medial orbital wall from an anterior to
posterior direction). The carotid artery can be exposed drilling very carefully the lateral
wall of sphenoid sinus. The intradural extension of the tumor needs dural opening and
careful microsurgical exposure and dissection from relevant structures. Complex cases
can include extradural and intradural involvement of carotid arteries and optic nerves
(Figure 8).
Fig. 4 Recurrent low grade sarcoma.

Nasal cavity, paranasal sinuses and
intracranial-intradural invasion (A and
B). The tumor is seen through the left
nostril.
Fig. 5 Intraoperative view after tumoral resection (A) of the case of figure 5. Arrows are pointing out
both orbits. The tumor has been removed from the midbase. DP= Dural patch (cadaveric liofilized
dura). Postoperative MRI (B) showing radical resection. The bright signal (arrow) corresponds with
autologous fat. This patient was one of the early cases done by the author. The patient developed
extradural infection. Now, fat is not used anymore near aerial cavities, and dural reconstruction is always
done with autologous pericranium or fascia.
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Fig. 6 16 years old boy with progressive loss of vision. CT scan (A) showing
recurrent osseus hemangioma, operated on two years ago. Intraoperative view
(B) after resection and bilateral extradural optic nerve decompresion. Left
optic nerve and carotid artery (arrow, C) after drilling. Postoperative CT scan
(D) shows no remaining tumor.
Fig. 7 12 years girl with headache and right blindness. RMN showing a very invasive neoplasm at of
presumed bony origin the anterior fossa (B). Both carotid arteries are encased by the tumor.
Intraoperative picture showing optic nerve decompression. The tumor was removed subtotally.
Histological diagnosis: Osteosarcoma
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Clivectomy and posterior fossa involvement

The retraction of both frontal lobes allows for exposure of the region of the pituitary
gland, sphenoid sinus and clivus. The tumor involving the clivus (Figure 9) can be
removed. If the tumor penetrates the clival dural plane, the posterior fossa can be also
reached (Figure 8). We have to take into account that the posterior clinoid region is
considered a blind area (dead angle) for the microsurgical approach. If the tumor is
Fig. 8 Simultaneous extra and intradural invasion of the neurovascular

structures at the anterior fossa. Recurrent malignant meningioma
Fig. 9 Clival chordoma. Sagital MRI showing the hour-glass growing at

the preclival area and posterior fossa (A, B, C). The tumor is located between
both carotid arteries and cavernous sinus at the midbase (D).
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Fig. 10 Patient of figure 9. Extended subfrontal approach. Surgical steps: 1) Removal of the preclival
portion. 2) Drilling of the clivus (A). 3) Removal of the posterior fossa component. Reconstruction
with pericraneal graft (PG). MRI one month after surgery, showing that the brain stem compression
has disappeared (B) and after three years (C). The pericraneal graft has lost some volume.
intermingled with the sphenoidal bone (as chordoma does), the drill with diamond burr
is very helpful (Figure 10). Laterally, the cavernous sinus and the hypoglossal canal are
the limits of the clivectomy.
Modifications of the technique. Complementary approaches

The extended subfrontal approach is very helpful for complex tumors involving the
fronto-naso-ethmoid midbase, usually with intracranial and intradural extension.
When the tumor is growing far from the midbase corridor, the extended subfrontal
approach must be modified adding complementary osteotomies at the lateral skull
base or facial skeleton.
For those cases that affect the spheno-ethmoidal region with almost no intracranial
extension, the subcranial approach (popularized by Raveh) is very suitable. The access
is given by a limited osteotomy of the frontal sinus, exposing the subcranial region. Only
small intradural-intracranial extension can be controlled with this route.
When the tumor is growing lateral to the cavernous sinus, a orbito-zygomatic
ostetomy is added to the bifrontal and orbital rim ostetomy (anterolateral resection). The
extradural-infratemporal component of the tumor can be reached (Figures 11 and 12).
If the tumor is involving the anterior fossa and also the facial skeleton beyond the scope
of the subfrontal view, an additional transfacial approach can be done. This is the
principle of the craniofacial resection, usually done to resect malignant tumors involving
the lower, lateral, anterior or posterior maxillary walls. The transfacial approach includes
a facial Weber-Fergusson incision and partial or total maxillectomy (Figure 13).
The extended subfrontal approach can be also combined with Le Fort I osteotomy,
facial degloving and transorbital approach. The transfrontal-transorbital approach is
indicated for resection of malignant tumors that penetrates the bony orbit and its
content. The orbit must be exenterated with meticulous dissection. The filling and
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Fig. 11 Nasopharyngeal Juvenile Angiofibroma. Involvement of anterior fossa with

lateral paracavernous and infratemporal extension. Angiography showed the typical high
vascularization of this tumor, with a very important supply from the external and internal
carotid artery.
Fig. 12 Same patient of figure 12. Total

resection after combined skull base
procedure: antero-lateral approach
combined with transfacial LeFort I approach
with midline sagital section. Bifrontal
craniotomy including some area of the
temporal skull vault (A). Fronto-orbitozygomatic osteotomy osteotomy (B)
allowing for the control of the lateral
extradural component of the lesion.
Intraoperative view of the transfacial
approach and complete removal of the
tumor (C).
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Fig. 13 Chondrosarcoma with maxillary, orbital and anterior fossa involvement (A and B).
Postoperative CT scan showing (C) orbital and anterior fossa reconstruction with temporal
muscle (single arrow) in continuity with pericraneal and contralateral temporal fascia
(single flap; double arrow). Intraoperative view (D) showing the temporal muscle nicely
epitelized several weeks after surgery, restoring the anatomy and function of the palatal region.
reconstruction of the orbital cavity can be done with temporal muscle or free muscle
transfer (microvascular flap) from rectus abdominis or radial antebraquial area.
Reconstruction
The reconstruction of the different anatomical elements after surgical approach and
tumoral resection is one of the most important steps of the procedure. Any dural
defect should be repaired, by direct suture or by means or dural patch. Autologous graft
from vicinity must be used, rather than alien materials. The pericranial tissue is the first
choice, although the temporal fascia can be also used. The most problematic defects are
those at the subfrontal area in the vicinity of the anterior clinoid, tuberculum sellae and
lesser sphenoid wing, where the dural layer is very thin. If the dura is infiltrated by the
tumor and must be resected, the probability of a watertight closure is very low and the
risk of CSF fistula and/or pneumochephalus is very high. Tenting sutures try to avoid
extradural fluid accumulation and dead space.
The bony skull base is also reconstructed with the aid of microplates. The frontoorbital
badeau is secured to the frontal bone after removing the mucosa of the frontal sinus,
previously exposed. The midbase defect (between both orbits) only the interposition of
soft tissue (pericraneal vascularized flap; galea-frontalis flap) trying to insulate the
intracranial cavity from the nasal and paranasal cavity. This technique prevents also from
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Fig. 14 Steps of the reconstruction

of the anterior skull base (patient
of figure 8). Pericraneal graft
covering the anterior fossa (A and
B). Bifrontal craniotomy and
orbito-frontal flap (C and D). Bony
assembly with the aid of microplates
(E and F).
any possible herniation of the intracranial content (Figure 14). There is no need of
interposition of any bone (as formerly done). Fat graft is not advisable if there is some
possible contact with the aerial cavity. The temporal muscle can be used also for
anterior fossa reconstruction, after proper rotation. If maxillectomy has been done, the
temporal muscle can be very useful restoring the anatomy and fuction. As a rule, non
biologic alien materials should be avoided, as they increase the probability of infection.
Before closure of the skin, a drainage system is left at the subgaleal space.
POSTOPERATIVE CARE
The postoperative care in this patients is of paramount importance. Antibiotic should
be administered perioperatively. The subgaleal drainage is kept no more tan two days,
paying attention to the vacuum pressure: If the dural plane has not been watertight closed,
CSF aspiration can lead to serious complications. The spinal drainage is kept initially
closed after surgery, as the release of CSF can provoke mental disturbance that can be
misleading in the immediate postoperative period. If there is some suspicion of CSF leak,
the drainage is opened. A daily CSF sample can be taken, checking cellularity and
glucose. Any increase of the cellularity and lowering of the glucose must be interpreted
as possible CSF infection and culture must be done. The patient must be seated and
walking as soon as possible, to avoid complications related to bedridden. Care must be
also taken regarding the avoidance of pulmonary infection, as cough may inject
contaminated air into the cranial (and even intradural) cavity, increasing the risk of
pneumocephalus, meningitis and extradural empyema (Figure 15).
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Fig. 15 Pneumonia in the postoperative

period with persistent cough (patient of
figure 8). Headache and deorientation
due to pneumocephalus with mass effect
(A). Coronal MRI (B). The arrow is
pointing out the bubbles of air after
entering the intradural cavity beacuse
of failure in the reconstruction. The
tumor resection included the paraclinoid
dura, precluding the reconstruction in a
watertight fashion.
CONCLUSIONS
Complex tumors at the anterior skull base are a formidable and challenging problem
for the neurosurgeon. The simultaneous involvement of several anatomical compartments
and the intricate anatomy of the region make surgery difficult and risky. Complications
associated to these approaches are very common, many of them associated with failures
in the reconstruction of the skull base.
FURTHER READINGS
1. Arita N, Mori S, Sano M, Hayakawa T, Nakao K, Kanai N, Mogami H. Surgical
treatment of tumors in the anterior skull base using the transbasal approach.
Neurosurgery. 1989 Mar;24(3):379-84
2. Chandler JP, Pelzer HJ, Bendok BB, Hunt Batjer H, Salehi SA. Advances in surgical
management of malignancies of the cranial base: the extended transbasal approach. J
Neurooncol 2005 73(2):145-52.
3. Chandler JP, Silva FE.Extended transbasal approach to skull base tumors. Technical
nuances and review of the literature. Oncology 2005 Jun;19(7):913-9
4. Feiz-Erfan I, Han PP, Spetzler RF, Horn EM, Klopfenstein JD, Porter RW, Ferreira, MA,
Beals SP, Lettieri SC, Joganic EF. The radical transbasal approach for resection of
anterior and midline skull base lesions. J Neurosurg 2005 103(3):485-90.
5. Honeybul S, Neil-Dwyer G, Lang DA, Evans BT, Weller RO, Gill J. The extended
transbasal approach: a quantitative anatomical and histological study. Acta Neurochir
(Wien). 1999;141(3):251-9.
6. Kawakami K, Yamanouchi Y, Kawamura Y, Matsumura H. Operative approach to the
frontal skull base: extensive transbasal approach. Neurosurgery. 1991 May;28(5):720-4.
7. Kurtsoy A, Menku A, Tucer B, Suat Oktem I, Akdemir H, Kemal Koc R. Transbasal
approaches: surgical details, pitfalls and avoidances. Neurosurg Rev. 2004 Oct;27(4):26773.
8. Lang DA, Honeybul S, Neil-Dwyer G, Evans BT, Weller RO, Gill J. The extended
transbasal approach: clinical applications and complications. Acta Neurochir(Wien)
1999;141(6):579-85.
9. Sekhar LN, Nanda A, Sen CN, Snyderman CN, Janecka IP. The extended frontal
approach to tumors of the anterior, middle, and posterior skull base. J Neurosurg.
1992 Feb;76(2):198-206.
10. Spetzler RF, Herman JM, Beals S, Joganic E, Milligan J. Preservation of olfaction in
anterior craniofacial approaches. J Neurosurg. 1993 Jul;79(1):48-52.
174
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Parasellar Meningioma
(Tuberculum Sellae Meningioma)
HEE-WON JUNG and CHUL-KEE PARK
Department of Neurosurgery, Seoul National University College of Medicine
Key words: Tuberculum Sellar Meningiomas, Visual Coutome, Approach
Introduction
Tuberculum sellae meningioma is midline tumor that originates from the dura of
planum sphenoidale, limbus sphenoidale, chiasmatic sulcus, tuberculum sellae, and
diaphragm sellae. Sometimes the tumor involves the dura of the anterior clinoid process
and medial surface of optic canal. The most common presenting symptoms and signs are
visual disturbances that are asymmetric, starting in one eye, worsen, and then spread to
the other eye. This is due to the tumor displaces the optic nerve and chiasm
posterolaterally. Therefore, visual field defect usually starts from the temporal area.
The blood supply to the tumor is frequently from the ethmoidal branches of the
ophthalmic artery, the anterior branch of the middle meningeal artery, and the meningeal
branches of the internal carotid artery.
Surgical resection of the tumor is the treatment of choice. Various approaches are
possible for the access to the tumor including unilateral subfrontal approach, pterional
approach, orbitopterional approach, bifrontal interhemispheric approach, and
transsphenoidal approach. Whatever the surgical approach, the main steps of the tumor
resection are the devascularization of the basal blood supply, followed by internal
debulking and capsule dissection. Small sized tumors can be removed by unilateral
subfrontal approach or pterional approach. Medium sized tumors with possible anterior
clinoid process and optic canal involvement can be more safely removed by
orbitopterional approach with anterior clinoidectomy with better chances for the
preservation of visual function. (Figure 1) Larger tumors, although it is not an usual
situation for tuberculum sellae meningiomas as visual disturbance in relatively early stage
renders the diagnosis of the tumor, needs greater surgical flexibility which can be
provided by bifrontal interhemispheric approach.
The surgical procedure of the orbitopterional approach for the resection of the
tuberculum sellae meningioma is described in this chapter. The orbitopterional approach
has several advantages. Firstly, working distance during the surgery is much shorter than
any other approaches. Secondly, removal of bony obstacles including anterior clinoidal
process and orbital roof extradurally before debulking a tumor provides sufficient
space for tumor dissection and helps preserving visual function by securing the optic
nerve from excessive stretching during manipulation. Thirdly, with minimal brain
retraction, upper portion of the tumor can be visualized so that safe dissection of
tumor from inferior part of the optic apparatus can be performed more safely.
Meningioma (Tuberculum
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Fig. 1 Magnetic resonance (MR) images showed a 3.5x 3.5 x 3.5 cm sized mass, in the sellar and
suprasellar region, which compressed optic chiasm and compressing both bilateral intracerebral
arteries and anterior cerebral arteries based on tuberculum sellae, chiasmatic sulcus, limbus sphenoidale,
and diaphragma sellae.
Surgical procedure
Position
Supine with the head turned 30 degree from midline parallel to the floor, inclined
slightly downward to minimize torsion to the contralateral jugular vein, and skeletal
fixation was done. Lumbar puncture and cerebrospinal fluid drainage is optional
procedure to aid exposure and preventing excessive brain retraction. In determining the
side of the unilateral surgical approach, it is reasonable to choose the direction of the
worse vision due to it is usually correspond to the side of the greater tumor extension
which requires early relief of optic apparatus compression during surgery.
Craniotomy and clinoidectomy

An extended curvilinear frontotemporal incision acrossing the midline is made
starting from just anterior to the tragus to ensure the exposure of orbital rim. The
skin flap and the temporalis muscle are elevated utilizing the interfascial technique to
protect the frontalis nerve and reflected as separate layers. After exposure of
frontotemporal bone including the superior orbital rim and the frontal process of
zygoma, key burr hole is made just behind the junction of the frontal root of the
zygoma followed by additional burr holes at temporal and frontal bone. It is much
convenient if the key burr hole can be cover the anterior fossa, middle fossa and orbit
simultaneously. A standard frontotemporal craniotomy using these burr holes is
performed. Anterior frontal margin should be parallel to the superior orbital rim
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carefully avoiding the margin of the frontal sinus. And then the periorbita is dissected off
of the superior and lateral side of orbit, and the supraorbital nerve is dissected from its
notch. To remove the orbital rim, the initial cut is made from the key hole to the
frontal process of zygoma. Osteotomes are then used at the orbital roof from key hole to
the medial craniotomy edge of orbital rim only to elevated and fractured. (Figure 2) It
is also recommendable to make a single craniotomy flap without making a cut at the
supraorbital area.
Fig. 2 Burr hole placement and craniotomy lines for orbitopterional approach.
The lateral sphenoid ridge is drilled. When the sphenoid ridge drilling approaches to
the anterior clinoid process, the dura is then circumferentially dissected off the anterior
clinoid process. The anterior clinoid process is then removed after drilling the root of the
anterior clinoid process to the optic strut and by gentle fracture. Caution is needed to
avoid any injury to optic nerve, ophthalmic artery and internal carotid artery. Unroofing
of the optic canal is needed additionally if the tumor has grown into the optic canal. This
early removal of anterior clinoidal process done extradurally before debulking a tumor
provides sufficient space for tumor dissection and helps preserving visual acuity by
securing the optic nerve from excessive stretching during manipulation.
Tumor removal
A curvilinear dural incision is made centered on the sylvian fissure. After sylvian
dissection and gentle frontal lobe retraction, the tumor compressing optic apparatus and
internal carotid artery is exposed. Usually thin pale optic nerve angulated against
falciform ligament is identified superiorly or superolaterally of the tumor.
Devascularization of the tumor from the anterior part of tumor origin, that is usually
planum sphenoidale, is performed. And then the debulking of tumor is done with
suction, the ultrasonic aspirator, or a bipolar coagulator and microscissors. After
sufficient internal debulking of the tumor, the dissection of the tumor surface tracing
arachnoid membrane is performed carefully. Once dissection approaches the
neurovascular structures, only bi-polar cautery and microdissection should be used.
Despite apparent encasement or severe adherence of the optic nerve, a plane of dissection
Meningioma (Tuberculum
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Fig. 3 After complete removal of the mass well-preserved structures, bilateral optic
nerves decompressed, right ICA and its bifurcation, ACA, pituitary stalk, and MCA and
its branches are presented. The origin of tumor is coagulated and removed clinoid
process was marked with slanting lines. (ACA: anterior cerebral artery, ICA:
intracerbral artery, L: left, MCA: middle cerebral artery, ON: optic nerve, Rt: right)
can be obtained under high magnification. Dissection is then continued to free the middle
and anterior cerebral arteries. Arterial supply to the optic nerves and chiasm, especially
on the inferior surface of the optic apparatus from superior hypophyseal artery, should
be preserved by keeping an arachnoid plane during the sharp microdissection. If the
tumor grows into the optic canal, it can be removed by curettage with ring curette. This
procedure is accompanied with early release of optic nerve by anterior clinoidectomy and
unroofing of optic canal. After the tumor has been removed, the origin of tumor is
coagulated once again. (Figure 3)
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Closure
The dura is closed in a water-tight fashion. The bone flaps are repositioned and
secured with miniplates and screws. It is important to make a good alignment in orbital
rim due to the cosmetic outcome. The muscular flap and the skin are closed layer by layer.
After surgery, visual assessment should be done in a week and followed-up carefully
afterwards. Short-term postoperative visual outcome is a strong indicator of permanent
visual outcome after surgery for tuberculum sellae meningioma, and recurrence or
regrowth of tumor can be detected by the deterioration of visual function very sensitively.
One point memo

1. In determining the side of the unilateral surgical approach, it is reasonable to
choose the side of the worse vision as it usually corresponds to the side of the greater
tumor extension, which requires early relief by optic apparatus decompression by
surgery.
2. Removal of anterior clinoidal process extradurally before debulking a tumor
provides sufficient space for tumor dissection and helps preserving visual acuity by
securing the optic nerve from excessive stretching during manipulation.
3. Arterial supply to the optic nerves and chiasm, especially on the inferior surface of
the optic apparatus from superior hypophyseal artery, should be preserved by
keeping and arachnoid plane using the sharp microdissection.
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Petroclival Meningioma
LIXIN M.D., ZHAO JIZONG M.D.
Department of Neurosurgery Beijing Tiantan Hospital
Key words: meningioma, Petroclival, casediscussion
A 48-year-old female presented with a-year history of leflower extremity weakness, a

several history of occasional nausea and vomiting. Several years prior to her admission.
She was medically treated for trigeminal neuralgia on the right side, which has subsided
temporarily, but recurred without carbamazepine. Her general examination was normal
and neurological examination revealed the muscle strength of left lower extremity was
grade - without pathological positive signs.
Preoperative MRI scans revealed a mass with stronenhancement after the admission
of gadolinium diethylenetriamine penta-acetic acid, involving the petrous ridge, CPA area,
tentorium, and middle cranial fossa on soft tissue windows.(A,B,C). Its size was
approximately 555 cm. Moderate compression of the brainstem was demonstrated
from this extraaxial lesion. The diagnosis was a petroclival meningioma according to the
history and radiological findings.
We performed a presigmoid infra- and supratentorial approach to remove the tumor
from the posterior and middle fossae. This photographs showed a Horseshoe shape skin
line(D,E) which began from up margin of zygomatic arch termination and end to 2cm
apart from post aurem. Intraoperative the petrous bone was grinding and the superior
petrous sinus(F) was ligated. The tumor(G) was exposed after incided the dura mater. The
whole procedure was difficult and the tumor could only be resected piecemeal, We
carefully protected CNs , , 1, - intraoperative. The patient sustained a
temporary palsy of CNs postoperatively(O). Because the dura was partially defect we
Axial(A) , coronal(B) and sagittal(C) T1WI with contrast enhancement show an homogeneous totally
enhancing extraaxial mass, involving the petrous ridge, CPA area, tentorium, and middle cranial fossa.
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J
H
repaired the dura with artificial dura and replaced the two bone flaps like photo(H) with
Craniofix-clamp for avoiding a CSF collection under the skin flap and CSF skin fistula.
Pathological examination was revealed it was a meningothelial meningioma(J). The
postoperative MRI and CT scans confirmed a totally removement of the tumor
(k,L,M,N).
Petroclival Meningioma
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309
The patient sustained a temporary palsy of CNs which demonstrated that she could
not fully open her right up eyelid postoperatively(O). She recovered smoothly without
facial nerve palsy and eyeball motion nerves. Her preoperative symptoms such as left
lower extremity weakness and trigeminal neuralgia recovered 1-month after operation.
N
O
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The optimal protocol of treatment for

petroclival meningioma
TETSUO KANNO, KOSTADIN KARAGIOZOV
Department of Neurosurgery, Fujita Health University
Key words: petroclival meningioma, surgical approach, treatment protocol, results
I. Introduction
Petroclival meningiomas remains one of the most difficult lesions for surgical
removal. Their location in the midline and between the middle fossae on both sides makes
the approach to this lesion through a craniotomy very deep and complex as at the
same time they involve critically important nerves, arteries and veins. (Fig.1)
Fig. 1
Although the surgical mortality dramatically reduced in recent years, the surgical
morbidity remains significantly high. On the other hand, it is slowly growing
meningioma. Therefore, the optimal treatment protocol is still controversial.
II. Cases and long-term result

The authors experience(these are the personal series of TK) is based on 138 cases of
which 43 cases were operated by retrosigmoid approach, 38 - by combined petrous
approach and 57 - by retrosigmoid plus orbitozygomatic approach. (Fig.2,3)
Th
Thee optimal protocol of treatment for petroclival meningioma
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Fig. 2
Fig. 3
Gross total resection for tumors arising from petrous apex was 95.3%, however, in
tumors with some extension to clivus, the gross total removal was 26.3%. In tumors with
some extension to cavernous sinus the gross total removal was 59.7%. The low rate of
gross total removal, particularly in cases with tumor extension to clivus is because of
tumors strong attachment to brain stem and/or an artery is passing through the tumor
(Fig.4).
The reason of the low rate of complete removal in cases with tumor extension to
cavernous sinus was the involvement the preoperatively non-symptomatic cranial
nerves. (Fig.5)
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Fig. 4
Fig. 5 cranial nerves.
Th
Thee optimal protocol of treatment for petroclival meningioma
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The overall complication rate was 41%, of which new cranial nerve deficit was in 30%
and facial nerve particularly was worse in 23% of the operated (Fig.6)
The excellent resection with a low rate of morbidity depends upon,
1) The presence of Arachnoid membrane around the tumor
2) The consistence of the tumor (hard and fibrous vs. soft and succable)
3) The degree of its involvement with critical neurovascular structures.
Fig. 6
Fig. 7
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III. Available results of other authors

Fig.7 shows the results of surgery for petroclival meningioma by various authors in
literatures. The mortality ranges between 0~10% (average 4.11%), and the morbidity
between 11~59% (average 24%). These rates are still high. We must take into account also
the new cranial nerve palsy, which ranges between 22~91% (average of 46%), and the
gross total resection - from 26 to 85% (average 63%). (Fig.7) We have to accept that these
studies have not yet shown satisfactory results.
IV. Radiosurgery
On the other hand, the radiosurgery shows a rather good result so far.
They revealed a good tumor growth control rate.
Kondziolka (Neurosurgery 2008) showed 93% of overall control rate.
V. Conclusion
The optimal protocol of the treatment for petroclival meningioma is still controversial.
The reason of this controversy is mainly due to high morbidity and impairment of the
postoperative quality of life. This high morbidity makes the patients unhappy.
On the other hand radiosurgery also remains controversial. We need longer follow up
to estimate permanent control and cure rates, comparing to surgery..
Therefore the authors can recommend subtotal removal (safe of complications )
followed by radiosurgery.
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Foramen magnum meningioma

MITSUHIRO HASEGAWA, KOICHIRO YOSHIDA, TSUKASA KAWASE,
JUNKO MATSUYAMA, YUICHI HIROSE
Department of Neurosurgery, Fujita Health University, Japan
Key words: foramen magnum, meningioma, transcondyle approach, vertebral artery
Introduction
Meningiomas are the most common benign tumors of the foramen magnum.
However, the frequency is approximately 1 % of all intracranial meningiomas and this
lesion involves lower part of brainstem and lower cranial nerves for live-threatening vital
functions. Therefore, this is one of the most challenging surgery for neurosurgeons
because of the rarity and the location. Both understanding precise surgical anatomies,
selection of proper approaches, and performing meticulous microsurgical techniques are
mandatory. Clinically, motor weakness is main symptom, and followed by nuchal
rigidity, sensory disturbance, coordination disturbance, and dysphasia. Approximately
60% of foramen magnum meningiomas are located antero-lateraly, 25% anteriorly, and
10% posteriorly (figure 1).
Fig. 1 Locations of foramen magnum meningiomas.

Circles indicate attachment of anterior (red circle),
antero-lateral (blue), and posterolateral (yellow) type
foramen magnum meningiomas.
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Surgical procedure
For posteriorly located foramen magnum meningiomas, midline suboccipital approach
can be used associated with or without C1 laminectomy. The tumors attached to the
anterior and anterolateral margin of the foramen magnum can be given access by
lower lateral suboccipital approach with the several additional corridors advocated
depending on the tumor location and the size; conventional posterior suboccipital
approach, suboccipital transcondylar approach, transcondylar fossa approach
(supracondylar transjugular tubercle approach), far lateral approach combined with and
without transposition of SS, extreme lateral approach, extreme lateral infrajugular
trans-tubercular exposure, and transoral approach.
Position and skin incision

(lower lateral suboccipital approach)
The patient is placed in the lateral oblique position (figure 2). The head is placed in
the lateral position with the face oriented slightly flexed with vertex down to gain wide
space between head and shoulder. Monitoring should be applied (figure 3): NIM
response for facial nerve function, an electromyography from endotracheal tube for
function of recurrent laryngeal nerve and superior laryngeal nerve (Xth CN), macroscopic
muscle movement of trapezius muscle for accessory nerve, and ABR and SEP for
brainstem function.
The incision is blunt S-shape or hockey-stick. The suboccipital triangle is exposed, and
access the horizontal portion of extradural vertebral artery on the C1 vertebral sulcus.
Fig. 2 Schematic drawings and photos

of operative position and skin incision
for lower lateral approach. For
posterolateral type foramen magnum
meningiomas, standard prone position
is applied.
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Fig. 3 A photo of setting for intraoperative

monitorings for facial, vagal nerves, and SEP.
Craniotomy (figure 4)
The procedure consists of the posterior fossa craniotomy (craniectomy), opening the
foramen magnum, and C1 hemi-laminectomy, drilling posteromedial one third of the
condyle (transcondyle approach), drilling occipital bone of condyle fossa (transcondyle
fossa approach), infrajugular drilling to open hypoglossal canal (ELITE) are added, if
necessary, depending upon the lesions extension (figure 5). Usually drilling of jugular
tubercle (transjugular tubercle approach) or presigmoid drilling is not necessary for
foramen magnum meningiomas.
The extradural vertebral artery (V3 segment) can be mobilized out with venous
plexus of the vertebral groove on C1, so that C1 lamina can be removed safely as lateral
as possible up to C1 lateral mass. The resection of additional occipital bone and the
posteromedial one third of the occipital condyle and lateral mass of C1 can give easy
access to the anterior part of the foramen magnum.
Fig. 4 Standard craniotomy (left, yellow line indicates midline craniotomy and red line indicates
lower lateral craniotomy) and postoperative 3D-CT image of craniotomy of posterior midline from
outside (right).
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Fig. 5 Anatomy around the condylar fossa and compartments of craniotomy sites on dry bone.
Dural opening and tumor removal

A curvilinear dural incision begins at the superior-lateral part of the craniotomy,
extends through foramen magnum to lower part of the laminectomy. Bleeding from
marginal and occipital sinuses is managed by coagulation by bipolar forceps and/or
hemoclip. The posterior fossa and spinal dura are reflected laterally with retraction
stitches. The injury of the cerebellar surface is avoided. CSF is aspirated at the cisterna
magna. The brain stem is displaced and rotated to the contralateral side by the tumor
bulk. The surgeon can access the lesion through the triangle medial and lateral to the
spinal root of XIth cranial nerve. Brain stem should never be retracted. After the
lower cranial nerves and spinal roots on the dorsal surface of the tumor and the course
of the vertebral artery in the direction of the basilar junction is identified, the surgeon
enters between these nerves, open a window in the tumor, internally decompress the
tumor, and coagulates the dural feeding arteries. After reaching and coagulating the
feeding dural arteries, the devascularized tumor can be removed by ultrasonic aspirator.
The peripheral dissection of the tumor is carefully performed without injury of
perforators. To expose and remove the tumor located in front of the cervico-medullary
junction, the dentate ligaments are cut and stitches are made to gently reflect the spinal
cord posteriorly.
Closure
The dura has to be closed in a watertight fashion to avoid CSF leak. Dural defect
should be replaced by homologous materials, such as fascia or muscle. The muscle and
fascia are approximated, superficial fascia and skin are sutured. Suction drain is usually
unnecessary. Pre- and postoperative MRIs and surgical views of representative three cases
are demonstrated in figures 6-10.
Fig. 6 Sagittal MRI of case 1 with anterolateral type of foramen magnum meningioma.
Postoperative MRI (right) indicates total removal.
Fig. 7 Surgical view and schematic illustration

of the same case of figure 6. The tumor
compresses brainstem posteriorly, and stretches
lower cranial nerves and high cervical dorsal
rootlets, making operative window (upper left).
Right photo indicates total removal.
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Fig. 8 Case 2 with anteriorly located small foramen magnum meningioma.

Preoperative (left) and postoperative (right) MRI, indicating total removal.
Fig. 9 Pre (left) and Postoperative (right) MRIs of case 3 with foramen magnum
meningioma. Huge meningioma involves bilateral vertebral arteries (red arrows),
the small tumor tissue, which adhered to VA and its perforators, was left behind
(yellow arrow).
Fig. 10 Surgical view and schematic

illustration of the same patient in
figure 9. The tumor was gross totally
removed, except tumor fragments
around the VA.
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Management of Vestibular Schwannoma

BASANT K MISRA
MBBS, MS, Mch, Diplomate National Board Consultant Neurosurgeon, Head of
the Department of Neurosurgery & Gamma Knife Surgery, P D Hinduja National
Hospital & Medical Research Centre, Veer Savarkar Marg, Mumbai, India
Key words: Schwannoma, gamma knife, CP angle, retromastoid approas, IAM,
translabyrintine approach
Introduction
Since its first successful removal, the history and progress of vestibular schwannoma
(VS) management parallels that of neurosurgery.1 Thus it is but natural that the present
day trend of minimal invasiveness should also have a major influence in the management
of a patient with VS. In fact, Cushings recommendation of subtotal excision in VS is as
old as neurosurgery itself.2 While the debate regarding the best microsurgical approach
to a given VS continues, it has been surpassed by the debate about the role of observation,
Gamma Knife Radiosurgery (GKR) and microsurgery in the management of VS. 3, 4
The changes that have taken place in the management of VS over the last two decades as
well as the current protocol, operative approach and results are presented here.5
History
Sandifort of Leyden (1777), Leveque-Lasource (1810) and Charles Bell (1830) are
widely credited with the first autopsy description, first clinico-pathological correlation
and first clinical description of VS respectively.2, 6 While Balance of London is commonly
credited with the first successful surgery in VS in 1892, Cushing credits Annandale of
Edinburgh with the first successful surgery in 1895.2 Seminal papers on the clinical
presentation by Cushing and neurological manifestation by House have laid the
foundation for the early diagnosis of VS.2, 7, 8
Atypical presentation of VS is not rare however, as has been highlighted in a classic
paper by Shephard and Wadia9. Though Cushing was the pioneer in achieving a
significant successful operative series of VS, Dandys outstanding results after total
excision of VS were equally important in paving the way for many neurosurgeons to
conquer what Cushing named the bloody angle, the gloomy corner of neurological
surgery.2, 10 Noteworthy contributions in refining microsurgical excision of VS have been
made by House, Malis, Yasargil and Samii over the years.8, 11, 12, 13 Lars Leksell, the founder
of Gamma Knife Radiosurgery and Ladislav Steiner from Sweden have established and
the Pittsburgh group popularised the role of radiosurgery as an established management
protocol in VS.14, 15
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Surgical Anatomy
The cerebellopontine fissure is a V-shaped fissure with the apex laterally where
cerebellum wraps around the pons and the middle cerebellar peduncle. The space
between the superior and inferior limb of the `V is referred to as the cerebellopontine
ange (CPA).16 The structures in the CPA are the AICA, pons, middle cerebellar peduncle,
petrosal surface of the cerebellum and the abducens, facial & vestibulocochlear nerves.
The fifth through the ninth cranial nerves arise in the area between the two limbs of the
`V shaped fissure. (Fig 1) The AICA arises from the basilar artery and courses in
relation to the abducens nerve and the pontomedullary sulcus and is called the premeatal
segment. The segment near the internal auditory meatus (IAM) is called the meatal
segment and supplies the nerves entering IAM. The branches arising from AICA here are
the labyrynthine artery supplying the 7th & 8th cranial nerves, the recurrent perforating
arteries, which have a recurrent course initially towards the IAM and then turn around
to supply the brainstem, and on injury produces brainstem infarct; and the subarcuate
artery which enters the subarcuate fossa and usually ends in the bone. The terminal
portion of the AICA is the postmeatal segment and supplies the brainstem and the
cerebellum.
Fig. 1 Normal anatomy of the right

cerebellopontine angle showing the disposition
of the cranial nerves and vessels. Note the 7th &
8th nerve complex just superior to the choroid
plexus at the lateral recess.
The facial and vestibulocochlear nerves arise near the flocculus at the lateral end of
pontomedullary sulcus (facial 1-2 mm anterior to vestibulocochlear) and abducens
nerve arises at the medial end of the sulcus. Identification of the 7th and 8th nerve at their
origin from the brain stem is facilitated by tracing upwards the line of junction of the
rootlets of IX, X & XI cranial nerves through the pontomedullary junction. The facial
nerve origin is about 2-3 mm above these rootlets just anterosuperior to the choroid
plexus in foramen of Luschka and floculus of cerebellum.
The internal auditory meatus (IAM) has a width of 9-10 mm and a height of 3-6 mm
and the internal auditory canal has a height of 3-7 mm and length of 6-7 mm. The 7th &
8th cranial nerves exit through the IAC by a constant relationship at its lateral end. The
canal is divided into superior and inferior compartment by a horizontal ridge, the
falciform crest. The facial nerve and the superior vestibular nerve are in the superior
compartment with facial nerve anteriorly separated from the superior vestibular nerve
324 Skull Base
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by a vertical bar. The cochlear nerve is anterior to inferior vestibular nerve in the
inferior compartment.
The cerebello mesencephalic fissure is continuous with superior limb below and the
cerebello-medullary fissure is continuous with the inferior limb above.
Pathology
Vestibular Schwannoma (VS) is a benign tumour, the commonest intracranial
schwannoma and constitutes about 8% of all intracranial tumours. VS arises from the
schwann cells investing the vestibular nerve arising from the inferior vestibular nerve in
50-70% of cases. The origin is from the junctional zone where the central and peripheral
myelin meets which is just medial to or inside the IAM. The growth rate of the VS is
variable from 2-10 mm/yr. The incidence of bilateral VS is about 5%. The clinical
features, modality of treatment and results of various treatment protocols depends
mainly on the size of the tumour. The author classifies them as (i) intracanalicular (ii)
small (upto 20 mm) (iii) medium (20<30 mm), (iv) large (30<40 mm) and (v) giant
tumours (40mm).
Clinical Features and Diagnosis.

The clinical features can be because of 1) 8th cranial nerve dysfunction : hearing loss,
balance problem, tinnitus, giddiness; 2) features attributable to the adjacent structures:
facial hypoesthesia, trigeminal neuralgia, facial paresis, lower cranial nerve dysfunction,
cerebellar dysfunction and brainstem dysfunction and 3) raised intracranial pressure with
or without hydrocephalus. While different combinations of the above features are
possible, the commonest and earliest presentations are progressive vestibulocochlear
dysfunction. Infact any patient with progressive unilateral hearing loss should be
suspected to have a VS and appropriately investigated. Detailed neuro-otological
evaluation will pick up VS in nearly 90% of the cases. The classical finding is a high
frequency sensoryneural hearing loss in pure tone audiogram and increase in the
latency of wave I-V and III-V in brainstem auditory evoke response (BAER).
With the easy availability of CT scan and MRI, plain X-ray of the skull is not routinely
performed. A CT scan of the brain will show a well defined isodense / hypodense lesion
in the CP angle centred around the IAM with enlargement of the IAM by the tumour.
MRI of the brain will show isointense / hypointense well defined lesion in the CP angle
centred and entering the IAM in T1W images and hyperintense in T2W images. There is
usually strong enhancement of tumour after contrast injection. Intratumoral and
peritumoral cysts and peritumoral CSF cap may be seen. With larger tumours, space
occupation distorting 4th ventricle and obstruction of CSF pathway may result in
hydrocephalus. Sometimes hydrocephalus may be associated without CSF flow
obstruction. This communicating type of hydrocephalus may be a result of increase CSF
protein.
316 Neuro-oncology
325
Management
The various options available in the management of VS are microsurgery, radiosurgery
and observation.
Microsurgery
In the microsurgical era, three different surgical approaches, retrosigmoid (RS),
translabyrinthine (TL) and the middle cranial fossa (MCF) are commonly utilised.
The MCF approach was developed by WF House in early 60s.8 It is indicated in small,
mainly intracanalicular tumours. Excellent facial function and hearing preservation is
possible and total excision of the tumour with its lateral extension in the IAM is easily
achieved. It is unsuitable in large tumours with posterior fossa extension and since
one has to work beyond the facial nerve to remove the tumour, the nerve is at risk. The
MCF approach is generally preferred by otolaryngologists.
The translabyrinthine approach was first suggested by Panse House reintroduced this
approach in the 60s. Popular among the otolaryngologists, its main advantage is reduced
cerebellar retraction and shortening of the operative distance. As hearing is sacrificed by
this approach, it is not appropriate in patients with preserved hearing. The other
disadvantages are increased operative time for bone work, CSF leak and inadequate
exposure of the brain stem surface in large tumours.
All the patients in the authors series have, however, been operated through the
retrosigmoid route as this is the only route, that is not only adequate for all sizes of
tumour but also suitable for preservation of facial function and hearing. No doubt
enough literature is available now to document TL & MCF approaches as excellent means
of tackling selected tumours.17 Though the authors have used both these approaches
extensively for other skull base lesions, it has not been necessary to change the strategy
of retrosigmoid route for VS over the years.18-23 The authors indication of microsurgery
as the first choice today are
All tumours > 2.5 cm in the largest diameter.
Any patient with brainstem dysfunction, significant mass effect, raised ICP or
rapidly progressing symptomatology.
Young patient (< 50 years) with any tumour size.
Radiosurgery
More and more cases of VS are being treated by radiosurgery the world over, especially
as patients are presenting earlier with smaller tumours. Minimal hospitalization, no
general anaesthesia and avoiding an open surgery are particularly appealing to the
patient. Reports of long-term control with good cranial nerve function has led to
increased enthusiasm for its use by the physician.24-27 Earlier reports of increased cranial
nerve dysfunction have reduced significantly with reduction of tumour dose. The
concern, however, is long-term control with the lower dosage. The other major concern
326 Skull Base
317
has been the risk of malignant degeneration following radiosurgery. However, to date,
there is no proof to suggest any realistic risk of malignancy following GKR.28 Presently 1214 Gray (Gy) is prescribed to 50% isodose in GKR. The reported long-term control rate
is between 93% and 97%. Though, there have been recent reports of even improved
hearing after GKR, preservation is unpredictable.29-31 Today our indications for GKR are
patients with tumours of 2.5 cm or less in maximum diameter and
high medical risk
elderly patients or
recurrent or residual tumour showing growth
Observation
Studies on the natural history of VS have shown that there are some tumours which
do not grow and remain static over a long period of time.3, 32 Intracanalicular acoustic
neuromas (ICAN), small tumours and tumours picked up incidentally, thus could
merit a period of follow up. Due to the low socioeconomic status of many patients and
poor follow-up in developing countries, one is weary of advising observation except in
ICAN. Though the numbers are not included in this series, the author has advised
observation in some patients mainly elderly, those with minimal or only
auditory/vestibular dysfunction, ICAN, and those with incidentally picked up tumours;
provided there is no doubt about follow-up of such patients.
Even today, the authors advocate microsurgery as the first choice in young patients
with tumours less than 2.5 cm as our results in this group are excellent with 100%
preservation of facial function and eradication of tumour for good. Our present
management protocol for extracanalicular VS is presented in Table 1.
Table 1
318 Neuro-oncology
327
Retromastoid approach for Acoustic Neuroma

Position
Till 1995, the author has operated most patients with VS, except a few intracanalicular
and small tumours, in the lateral decubitus position. Since 1996 most VS tumours
have been operated in the supine position with a sandbag under the shoulder ipsilateral
to tumour and the head elevated and turned parallel to the floor and held with Mayfield
clamp. (Fig 2) This position is however ill advised for patients with advanced age and
gross cervical spondylosis.
Fig. 2 Head position and incision work
Neurophysiological Monitoring
After positioning, EMG electrodes are placed in orbicularis oris, orbicularis oculi and
frontalis muscles for continuous facial nerve function monitoring. BAER monitoring is
done in patients in whom pre op BAER wave forms are elicitable. Once dura is opened
the anaesthetist withholds the paralysing drugs and subsequently titrates at low dose to
get adequate muscle contraction on direct testing of facial nerve. During difficult
dissection of the facial nerve, the stimulator dissector is extremely useful giving an
audio signal on touching the nerve.
Incision & Exposure

A vertical incision of 8-10cm long is made one fingerbreadth medial to the mastoid
groove and extends from two fingerbreadth above the line joining the occipital
protuberance to the mastoid downwards. The muscles are cut in the line of incision and
the occipital bone is exposed after subperiosteal retraction of muscles. The craniotomy
should expose the transverse sinus superiorly and sigmoid sinus laterally and not stop at
the mastoid emissary vein or mastoid air cells. In most cases of large tumours we also tend
to expose and often take out about 1cm of the posterior lip of foramen magnum. This
does help to relax tonsillar herniation and help release CSF from cistern magna in
large tumours reaching the foramen magnum. However, in small and medium size
328 Skull Base
319
tumours neither the foramen magnum is reached nor the posterior lip taken off. Once
craniotomy is completed, bone margins are meticulously waxed. The operative field is
copiously irrigated with normal saline and additionally draped. The whole team changes
gloves. A linear dural incision is employed parallel to and 2mm medial to the sigmoid
sinus. The lateral dural flap is reflected laterally by hitch sutures. If the brain is full the
dural opening is done under the microscope, and after a small opening at the lower end,
CSF is drained from cistern magna or the lateral medullary cistern before opening the full
length. Brain should be lax before the tumour is approached. The exposed lateral
surface of the cerebellum is covered with a strip of gelfoam and mild retraction of the
cerebellum is done superomedially just enough to expose the posterior surface of IAM
and the adjacent posterolateral surface of the tumour.
Tumour Management
Once the cerebellum is lax, about one cm of the posterior surface of the tumour is
exposed. After coagulating the petrous bone lateral to the IAM, the double layer of
arachnoid is peeled off from the posterior surface of the tumour and the tumour
arachnoid plane is reached. It is critical to define this plane before coagulating or
incising the tumour capsule. It is not necessary to sacrifice the petrosal vein in AN. Again
care is taken not to damage any loop of AICA on the posterior surface of the tumour.
Usually, all the extra tumoral vessels can be displaced away from the tumour along with
the arachnoid if this plane is maintained. One need not worry about the facial nerve on
the posterior surface of the tumour as it is almost never displaced posterior to the
tumour. The bare tumour is now incised and about 1 cm capsule of the tumour excised.
Intartumoral decompression is carried out using lancet knife, microcurette, ultrasonic
aspirator and suction. Unless and until the tumour is extremely vascular, intra tumoural
decompression can be carried out without simultaneous haemostasis by bipolar
coagulation. The lower cranial nerves and the trigeminal nerves remain in their arachnoid
contained subarachnoid space and should not be exposed. If the lower cranial nerves have
to be dissected and their arachnoid covering is opened, a thin sheet of gelfoam put over
these to avoid inadvertent injury by instruments. AICA and its branches also need to be
meticulously dissected off the lower pole of the tumour at this stage. Once sufficient
internal decompression is achieved and most of the posterior capsule of the tumour
removed, attention is focussed on the IAM. Usually, the subarcuate artery, a branch of
AICA ending in the subarcuate fossa, can be identified at the posterior lip of IAM,
coagulated and cut. However, occasionally AICA or its recurrent branch may be entering
the IAM to loop back or remain subperiosteal at the IAM for a few mm. It is important
that this is recognised and the vessel dissected off the bone before drilling IAM. The dura
over the posterior surface of the petrous bone lateral to IAM is incised in a semilunar
fashion and reflected medially upto the porus. The bare bone is drilled with a high speed
drill along with constant irrigation. Initially a cutting burr is used till a thin shell of bone
is left when a diamond drill is used. (Fig 3) It is crucial to know the distance of the
posterior semicircular canal and the crus commune from the IAM to decide how much
to drill. If these structures are lateral to an imaginary line extending from the medial side
of the sigmoid sinus to the fundus of IAM, then there is no risk of injury. But if the
320 Neuro-oncology
329
Fig. 3 Drilling of IAM after decompression of

the tumour.
structures are located medial to the line and the whole IAC is drilled, there is danger of
opening the labyrinth and risk of hearing loss. Drill not more than 6-8mm lateral to IAM
if hearing preservation is attempted. If the patient is already deaf, then drilling is
continued till the lateral end of the tumour is reached. The dura in the IAC is opened and
the tumour is debulked and then the capsule is dissected off the facial and cochlear nerves
after sectioning the vestibular nerves. The lateral end of the tumour is excised under
endoscope assistance. The nerve stimulator is very useful in identifying the facial nerve
at this stage. In patients with extensive destruction of the petrous bone by the tumour it
is often difficult to recognize the nerves even in the canal because of the displaced
anatomy. In the region just medial to the IAM the nerves are most adherent to the
tumour. Moreover, the nerves angulate sharply anterior medial to the IAM making it
difficult to trace the nerves medial from IAM. Hence, after tracing the nerves in the canal
one may try to locate the facial and cochlear nerve complex at the brainstem end
utilizing anatomical landmarks and physiological monitoring. Once the nerves have been
identified at the medial end, side to side dissection of the capsule from nerves results in
the best functional outcome, (fig 4) the capsule is dissected off the nerves from medial
to lateral to reach the IAM. Whenever dissection is difficult at one point and the
tumour arachnoid plane is lost one goes from another angle where the plane is intact.
Hence, it is not uncommon to reach the nerves from various directions rather than
dissecting in one direction alone. The blood supply to the tumour, mainly from the AICA
and its branches are interrupted close to the tumour with bipolar coagulation and
microscissors. If the tumour is still bleeding when only the anterior capsule is left,
which is not easily peeling off the brainstem surface, suspect anchoring by AICA or its
branch. It is important not to coagulate in the vicinity of the facial and cochlear nerves.
If the arachnoid integrity has been maintained there is no problem of haemostasis and
usually the field is clean and dry once the capsule is excised. However, in the event of
breach of arachnoid, not an uncommon event in large tumours, haemostasis should be
ensured carefully after raising the blood pressure by 10-20mms of Hg. Residual tumour
in large vascular neuroma can lead to haemorrhage and hence they should be carefully
observed and reoperated as soon as possible.18 The operating field is irrigated with
normal saline at room temperature. The drilled area in the IAM is waxed and then
covered with fat (earlier harvested from thigh) and fibrin glued to prevent it from
slipping from the IAM. (fig 5) The dura is closed with continuous suture and reinforced
330 Skull Base
Fig. 4 Dissection of the tumour from the 7th

& 8th cranial nerves anterior to the capsule.
321
Fig. 5 Fat graft glued to the IAM before

closing dura.
Fig. 6 Fat graft reinforcing dura closure and

mastoid air cells.
with a layer of fat. Again the mastoid air cells are carefully sealed with bonewax and
covered with a layer of fat.(fig 6) Before closure, haemostasis of the muscles is carefully
checked. The patient is routinely reversed from anaesthesia and extubated on the table.
However, in the event the patient is drowsy, tolerates the tube, the patient is extubated
in the ICU. In the rare event of patient needing to be paralysed and ventilated or dose not
recover quickly in the ICU it is safer to put an intraventricular drain and monitor ICP and
do a CT scan of the brain to see for any haematoma or unexpected finding.
Personal Experience
An analysis of 909 cases of cerebellopointine angle lesions operated by the author since
1987 yielded 559 cases of VS operated at two institutes, Shree Chitra Thirunal Institute
of Medical Sciences & Technology, Trivandrum and P.D. Hinduja National Hospital &
Medical Research Centre, Mumbai till 2008. Microsurgery was the primary option in 438
and GKR was done in 139, of which 18 were previously operated by the author. A
prescription dose of 13 Gray (Gy) to 50% isodose was employed in the majority of the
cases. A detailed analysis of microsurgically managed patients in two different periods
(100 consecutive patients each before 1993 and 2008) were compared to see the changing
322 Neuro-oncology
331
trend and document current results. Though not included in these figures, there were a
number of cases of VS which were only observed.
Results
A consecutive series of 100 cases of VS treated microsurgically by the author was
published in 1993.5 The changes in the treatment strategy and the results achieved
were analyzed by comparing the series of 1993 to 100 consecutive microsurgically
treated VS from 2005-2008. The tumour size was smaller in the second group indicating
earlier detection (Table 2). Inspite of a trend towards earlier detection, there were still 39%
of giant tumours in the 2008 group. The total excision rate was a high 94% in the first
phase while it was 83% in the second phase. It is important to mention that while the total
excision was classified on a post-operative contrast MRI in the 2nd phase, in the 93
series, CE CT scan was more often the post-operative imaging modality. In the second
phase, total excision rate was 100% in tumours less than three cm, 86% in tumours that
were three to four cm and 72% in giant tumours. The facial function was better in the
second phase with 96% facial nerve continuity in the later phase as opposed to 77% in
the earlier phase.
In the last 100 cases, overall 87% patients had facial nerve function of Grade III
House and Brackmann 7(HB) or better. (Table 3)
The post-operative facial function was directly related to the size of the tumour
(Table 4). Useful hearing was preserved in ten cases, six of whom had tumours larger than
three cm. One patient with a large tumour had improvement in his hearing
postoperatively after a total excision.
The microsurgical operative mortality was 1% in the earlier series and nil recently. In
fact there has been no operative mortality in the authors practice in the last decade, the
last case being one who succumbed from postoperative meningitis following CSF
rhinorrhoea in 1999. The commonest postoperative complication was cerebrospinal fluid
(CSF) rhinorrhoea (Table 5) occurring in nine patients, six of which required surgical
repair. Pseudomeningocoele occurred in six patients but all resolved on conservative
management. Postoperative lower cranial nerve (LCN) dysfunction, the bugbear of
the past, only occurred in one patient who did not have it preoperatively. The other eight
patients had it preoperatively. Four patients who were discharged with a nasogastric tube
or percutaneous endoscopic gastrostomy (PEG) tube had significant preoperative
swallowing difficulty. Only two of the six patients with postoperative chest infection had
normal preoperative LCN function. One patient had delayed wound infection which
required surgical drainage and repair. There was no case of meningitis and postoperative
haematoma. In the later series (2005-2008).
Gamma Knife Radiosurgery was generally reserved by the author for tumours less than
2.5 cm in diameter. Of the 139 patients thus treated, three failed treatment and needed
microsurgery. One patient had facial palsy from a previous operation (pre GK) in
another centre. In the other two, near total excision was achieved with preservation of
normal facial function. (Fig 7) Two patients developed transient grade II HB facial
weakness. Detailed evaluation of their hearing status is in progress. Another complaint
following GKR in some patients has been a pulling sensation in the face and some
332 Skull Base

Table 2
Table 3
Table 4
Table 5
323
324 Neuro-oncology
333
others have had paraesthesias. Symptoms of giddiness and imbalance often got worse after
GK and took longer to settle down than in microsurgery.
Fig. 7 a & b. Pre and 1 year post GK MRI Brain with contrast showing increased tumour size of VS, cyst
formation and significant mass effect. c. post microsurgery CECT scan showing near total excision of
tumour and d. normal facial function
Special Situations (SS): Some special clinical settings need particular mention. Our
protocols in such situations are as follows:SS 1: VS in a pregnant lady
(i) Patients with small tumours are allowed to carry on through pregnancy and
normal delivery.
(ii) Patients with tumours less than three cm but minimally symptomatic are
advised to continue pregnancy and elective Caesarean section delivery.
(iii) Symptomatic patients with large tumours are advised microsurgery, preferably
after the first trimester. Quick subtotal excision is performed to provide
maximum safety to both mother and child. The tumour is usually much
more vascular in pregnancy. The patient can then go for normal pregnancy and
delivery. The residual tumour, if significant, can then be excised at a later date.
334 Skull Base
325
SS 2: Cystic/Hemorrhagic tumour
Patients harbouring cystic tumours and those presenting with macrohemorrhages
should be treated by microsurgery. Large-size, Antoni B type tumours and
telangiectasia pattern in the tumour make it more prone to both cystic and
hemorrhagic transformation.17 These tumours have a friable capsule leading to
greater dissection difficulty. However no effort should be spared for total excision
as these have a higher risk of recurrence & postoperative hemorrhage.
SS 3: VS with malignant edema
Unlike meningiomas, VS are rarely associated with significant edema. Rarely,
however, there can be significant edema associated in VS (Fig 8). It is better in such
cases to electively do a two-stage microsurgery to achieve total excision with good
cranial nerve function.
Fig. 8 T2 MRI Brain of a patient with VS showing

malignant peritumoral oedema
SS 4: Microsurgery following failed radiosurgery

We have observed the following in the patients operated by us following failed
radiosurgery.
While more difficult than a virgin case (not more difficult than a redo
microsurgery), total excision with good results is possible.
Tumour is firm but less vascular.
The arachnoid is usually thicker and adherent to the tumour. In such cases, a thin
layer of tumour is better left attached to the brainstem/cranial nerves for better
functional outcome.
SS 5: VS in elderly (>65 yrs)
Elderly patients with incidentally picked-up tumours or with only long-standing
auditory/vestibular dysfunction should be observed for a period of time before
considering any treatment.
Patients with small tumours will generally not need any treatment in their
lifetime.
Patients presenting with NPH syndrome are better treated by a ventriculoperitoneal shunt and generally will not need direct surgery for the tumour.
While radiosurgery is the preferred modality for elderly patients with tumours less
326 Neuro-oncology
335
than three cm, patients with larger symptomatic tumours should be operated and
age alone should not be a criteria to withhold microsurgery. Dramatic
improvement in the quality of life is possible in such patients with microsurgery.
Conclusion: Vestibular Schwannomas of all sizes can be operated microsurgically by
the retrosigmoid approach with gratifying results. Both facial function and hearing
can be preserved after microsurgery even in large tumours; hence no effort should be
spared to save these nerves. There is no doubt, however, that some patients are better
served with GKR and yet some others by no intervention at all. Equally important to
remember is that microsurgery for VS is a major procedure, there is a steep learning curve
and one can lose a patient from a seemingly innocuous few drops of postoperative
CSF rhinorrhoea.
In summary, the approach for a given patient should be patient oriented and not
surgeon oriented. Meticulous attention to minute details of each aspect of microsurgery
is essential to avoid catastrophe. The indications of GKR and microsurgery are still
evolving. Selection of the appropriate option by a surgeon with ample experience,
though not easy, is critical to an optimal outcome.
Acknowledgement
The author is grateful to Dr. Harshad Purandare, Associate Consultant, Department
of Neurosurgery for the illustrations and Ms. Sudha Nair for preparation of the
manuscript.
REFERENCES
1. Moskowitz N, Long DM. Acoustic Neuromas: Historical Review of a century of
operative series.Neurosurgery Quarterly 1991; 1: 2-18.
2. Cushing H. Tumours of the Nervus Acusticus and the Syndrome of the Cerebellopontine
Angle: W.B. Saunders Co; 1 295, 1917
3. Raut VV, Walsh RM, Bath AP, et al. Conservative management of Vestibular
schwannomas Second review of a prospective longitudinal study. Clin-Otolaryng
Allied Sci. 2004;29: 505-14.
4. Pollock BE. Vestibular Schwannoma management, an evidence based comparison of
stereotactic radiosurgery and microsurgical resection. In: Progress in Neurosurgery.2008;
21: 222-27.
5. Misra BK, Rout D, Bhiladvala DB. Current Status of Acoustic Neuroma Surgery. In: Book
of Abstracts. Neuroconf, Madras; 1993.
6. Rand RW, Dirks DD, Morgan DE, Bentson JR: Acoustic Neuromas. In: J.R. Youmans
Neurological Surgery. 2nd Ed. W.B. Saunders Co. 1982; pp. 2967 3003
7. House JW, Brackmann DE. Facial nerve grading system. Otolaryngol. Head Neck Surg.
1985;93: 146-147
8. House WF : Monograph 2- Acoustic Neuroma : Arch. Otolaryngology 1968; 88: 575-715
9. Shephard RH,Wadia NH. Some observations on atypical features in Acoustic
Neuroma.Brain 1956;79: 282-318.
10. Dandy WE. Results of removal of acoustic tumours by the unilateral approach. A.M.A.
336 Skull Base
327
Arch Surg 1941; 42: 1026 1033.

11. Malis LI: Microsurgical treatment of acoustic neuromas. In: Honda H ed.
Microneurosurgery, Baltimore, Univ park press;1975. pp. 105-120
12. Yasargil MG, Fox JL. The microsurgical approach to Acoustic Neuroma. Surg. Neurol
1974; 2 : 393-398.
13. Mathies C, Samii M. Vestibular and auditory function: Options in large T3 and T4
tumour. Neurochirurgiere 2002; 48: 461-70
14. Prasad D, Steiner M, Steiner L. Gamma Surgery for vestibular schwannoma. J Neurosurg
2000; 92: 745-759.
15. Flickinger JC, Kondziolka D, Niranjan A, Lunsford LD. Results of Acoustic Neuroma
Radiosurgery : An analysis of 5 years experience using current methods. J Neurosurg
2001; 94: 1-6.
16. Rhoton AL. The three neurovascular complexes in the posterior fossa and vascular
compression syndromes. Clinical Neurosurgery 1994, 41: 112-149.
17. Haddad GF, Al-Mefty O. The road less travelled : Trans-temporal access to CPA. Clin
Neurosurg 1994; 41 : 150-167.
18. Misra BK, Rout D, Bhiladvala DB, Radhakrishnan V. Spontaneous haemorrhage in
Acoustic Neuromas. Br. J Neurosurgery 1995; 9 : 219-211.
19. Misra BK. Microsurgical Approach to Cerebello pontine angle tumour. In: 11th ICNS,
Monduzzi Editors 1997; 363-369.
20. Misra BK. Management of Acoustic Neuroma An overview in Brain tumour surgery.
In: T Kanno Ed. Japan Brain Tumour Society.2000; 133-138
21. Misra BK. Changing Trends in the management of acoustic neuroma. Progress in
Clinical Neurosciences. 2003; 18: 34-40
22. Misra BK, Recent Trends in the Management of Acoustic Neuroma. In: A.E. Khamlichi
Ed 13th World Congress of Neurological Surgery, Medimond. 2005; 213 220.
23. Misra BK. Modern management protocol and outcome in Acoustic Neuroma. Asian
Journal of Neurosurgery 2007;1: 30-36.
24. Gabert K, Regis J, Delsanti C et al. Preserving hearing function after Gamma Knife
Radiosurgery for Unilateral Vestibular Schwannoma . Neurochirugiere 2004; 50: 350
357.
25. Lunsford LD, Niranjan A, Flickingsr JL et al. Radiosurgery of Vestibular Schwannoma:
Summary of experience in 829 cases. JNS 2005; 102 (Suppl.): 195-9.
26. Kano H, Kondziolka D, Khan A, Flickinger JC, Lunsford LD : Predictors of hearing
preservation after stereotactic radiosurgery for acoustic neuroma. J Neurosurg 2009: Mar
13. [Epub ahead of print]
27. Thomas C, Di Maio S, Ma R, Vollans E, Chu C, Clark B et al. Hearing Preservation
following fractionated stereotactic radiotherapy for vestibular schwannomas: Prognostic
implications of cochlear dose. J Neurosurg 2007; 107: 917-26.
28. Rowe J, Grainger A, Walton L, Silcocks P et al. Risk of malignancy after Gamma Knife
Stereotactic Radiosurgery. Neurosurgery 2007; 60: 60 66.
29. Niranjan A, Lunsford D, Flickinger JC et al. Can hearing improve after acoustic tumour
radiosurgery? Neurosurg Clin N Am 1999;10: 305-316.
30. Regis J, Pellet W, Delsanti C et al. Functional outcome after Gamma Knife surgery or
Microsurgery for Vestibular Schwannomas. J. Neurosurg 2002; 97: 1091-100.
31. Niranjan A, Mathieu D, Flickingen JC, Kondziolka D, Lunsford LD. Hearing preservation
after intracanalicular vestibular schwannoma radiosurgery. Neurosurgery 2008; 63:
1054-62.
32. Ojemann RG : Management of Acoustic Neuroma. Clinical Neurosurgery 1993; 40 : 498535.
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Surgery of Vestibular Schwannomas

MADJID SAMII1, MD, PhD; VENELIN M. GERGANOV 2, MD, PhD
1
President - International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625

Hannover, Germany
2
Associate Neurosurgeon, Department of Neurosurgery, International Neuroscience
Institute-Hannover
Key words: vestibular schwanoma, neurofibromatosis, translabirintinne approach,
retrosigmoid approac
Vestibular schwannomas (VS) have been described in 1777 by Sandifort. Bell and
Cruveilhier described their typical clinical presentation and anatomical relationships in
the cerebellopontine angle (CPA) in the first half of the 19th century. The first successful
complete removal of VS was performed by Sir Charles Balance in 1894. Major
contributions have been made later on by Victor Horsley, von Eiselsberg, Fedor Krause,
Cushing, and Dandy. Cushing promoted subtotal removal and could decrease the
mortality rates from 20% in 1917 to only 4% in 1931. Dandy recommended total
tumor removal, which led to a higher mortality of 10% in his series. In 1904, Panse
introduced the translabyrinthine approach. Later, the middle fossa and transcochlear
approaches were developed, whereas neurosurgeons have relied primarily on the
retrosigmoid approach. The introduction of the operating microscope and microsurgery
revolutionized the surgery of VS. Over the years the goals of VS surgery have evolved from
avoiding mortalities, to preserving facial nerve function, and - lately - to preserving
hearing and good quality of life.
VS are benign typically slow- growing neoplasms that are thought to originate from
the Schwann cells of the superior or inferior vestibular nerves. The site of origin is the
Obersteiner-Redlich zone - the transition zone regarding myelin production. At this point
the central oligodenrocyte-myelin is substituted for by the peripheral or Schwann-cell
myelin. The zone is usually located in the medial part of the internal auditory canal and
that is the most common area of origin of VS. According to another hypothesis, VS
originate from a Schwann cell population associated with the vestibular ganglion (or
Scarpa's ganglion).
The annual incidence of VS is estimated to be between 0.5 and 1.7 per 100,000
persons (1,2). They are typical for the fifth to sixth decades of life. In children and young
patients they occur very rarely, usually in patients with neurofibromatosis type 2 (NF-2).
VS are the most common CPA tumor. They constitute 25- 33% of posterior cranial fossa
tumors and 75- 86% of CPA tumors (3,4,5).
VS occur sporadically or are associated with NF-2. The unilateral sporadic tumors are
approximately 95% of all VS. The remaining 5% are NF-2 - associated VS. NF-2 is an
inherited autosomal dominant disease caused by mutation at the chromosome band
22q12. The mutation affects a gene that encodes the protein Schwannomin/Merlin, which
338 Skull Base
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is important for cellular remodeling and growth regulation. Patients with NF-2 associated VS have a predisposition to formation of multiple tumors of the central
nervous system, characteristically bilateral VS, meningiomas, ependymomas, and
neurofibromas. Therefore, a close lifelong clinical and radiological monitoring is
mandatory.
The natural evolution of VS cannot be predicted. The estimated annual growth rate is
between 0.2 mm and 2 mm annual (6,7). Recent studies have shown that changes in
tumor growth can occur at varying intervals (6) and a precise growth pattern does not
exist.
The classical four stages of development of VS are: intracanalicular, cisternal,
brainstem compressive, and hydrocephalic. Each stage is characterized by a specific
clinical picture. Patients with intrameatal tumors present with vestibulocochlear nerve
dysfunction: hearing loss, tinnitus, and/or vestibular dysfunction. Hearing loss is usually
of insidious onset and is the most frequent symptom, observed in up to 95% of the
patients. Audiograms reveal high frequency sensorineural hearing loss and speech
discrimination is affected out of proportion to pure tone hearing loss. Vestibular
symptoms frequently are not recognized by the patients, but are always discovered
with special testing. During the cisternal stage progressive hearing loss might be
observed. A sense of dysequilibrium gradually replaces the vertigo. Later on trigeminal
symptoms, headache, and ataxia appear. Obstructive hydrocephalus results from
occlusion of CSF outflow at the stage of severe brainstem and fourth ventricle
compression. Contralateral long tract signs, severe gait disturbance, lower cranial nerve
palsies, visual loss, and signs of intracranial hypertension appear. Hydrocephalus may
develop as a consequence of tumor-induced obstruction at the level of fourth ventricle
and its outlets or is due to malabsorbtion of CSF.
Tumor size is the main predictor of treatment outcome in all CPA tumors and,
therefore, earlier diagnosis is of crucial importance. The diagnosis of VS relies on
history and physical examination, and is solidified by audiometric and radiologic
evaluations. On CT examination VS are typically isodense. Bone window high-resolution
CT is highly sensitive in regard to bony changes and erosion of IAC. MRI is the
diagnostic tool of choice, which allows precise assessment of the tumor type in most cases
(8). On T1-weighted MRI images VS are isointense to slightly hypointense and on T2weighted images they are hyperintense. They enhance intense and homogeneous with the
exception of cystic tumor parts. The radiological differential diagnosis between VS and
meningioma, which are the second most common CPA tumor, is based on several
criteria (Wilms): VS are centered at the widened IAC; erosion and/or dilatation of the IAC
are seen in 70% to 90% of the cases; they form an acute angle with the posterior surface
of the petrous bone; almost always extend into the IAC; calcifications are extremely rarely
found. Meningiomas are centered usually away from the IAC and have broad contact
with the petrous bone or the tentorium. The angle formed between the tumor and the
pyramid is obtuse. The IAC is not widened and the tumor rarely extends into the IAC.
Although secondary invasion of the IAC might be observed in 10 to 20%, primarily IAC
meningiomas are exceedingly rare. Calcification are frequent finding and the dural
"tail sign, although not pathognomonic, is visible in 60% to 72% of meningiomas.
Epidermoids are well-delineated cystic lesions that are usually isointense to CSF T1- and
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T2-weighted MR images. Precise diagnosis can be made with fluid-attenuated inversion

recovery imaging, diffusion-weighted imaging, and CISS spin-echo MR images.
The classification of VS is based either on their maximal diameter or on the degree of
extension in the CPA. One of the widely applied classifications segregates them into 5
categories - intracanalicular, tumors up to 1cm, from 1 to 2,5 cm, from 2,5 to 4cm, or
larger than 4cm (9). Much more important than the absolute size is the extension of the
tumor into CPA and its relation to the brain stem (7), because it is related to both
difficulty and outcome of surgery. The INI classification of VS (Samii classification of VS)
is presented on table 1.
The management options of VS are observation, radiation therapy, and microsurgical
removal via one of several operative approaches. With the wide introduction of modern
MRI facilities, an increasing number of asymptomatic intracanalicular VS is found.
The conservative approach - observation- is based upon the assumption that some of
them will not grow. As the natural evolution of VS is still unpredictable, this strategy
should be applied only in very carefully selected cases, with regular MRT follow-up (at
6 to 12 month intervals). Hearing loss may occur at any point and may not be related to
any changes of tumor size. Thus, a hearing- preserving surgery might become impossible.
Initial observation is an option in case of old and/or somatically unstable patients with
small asymptomatic tumors or tumors causing mild stable symptoms.
Radiosurgery is the most frequent type of radiotherapy used for VS (10,11). It aims at
achieving tumor control and success rates of 93- 98% have been reported. In 1.1 to 24%
late facial neuropathy appears and the rate of trigeminal dysfunction is 3 to 27%.
Hearing preservation is achieved in 56 to 77%. However, in 2 to 7 % of the cases
secondary tumor growth is observed. Surgical removal of such tumors is extremely
difficult due to the intense postradiational adhesions. In cases of large VS another
treatment option is the staged treatment, which includes microsurgical tumor debulking
and brain stem decompression at the first stage, followed by radiosurgery of the remnant
at a second stage (12).
The goal of surgery of VS is not simply complete tumor removal but functional
preservation of all cranial nerves and achieving a good quality of life. The three most
frequently used operative approaches are the translabyrinthine, the middle fossa and the
retrosigmoid.
The benefits of the translabyrinthine approach (9,13,14) are: avoidance of cerebellar
retraction, shorter distance to the tumor, and early identification of the facial nerve at the
lateral end of the IAC. Its drawbacks are: sacrifice to hearing, restricted access to the CPA,
difficult dissection and hemostasis close to the brain stem, as well as poor visualization
and access to the caudal cranial nerves.
The middle fossa approach (3,15,16) is a hearing preserving option that allows direct
access to the lateral end of the IAC. Thus, the most lateral part of the tumor could be
safely removed. The approach is related to low risk of CSF leaks. However, it is applicable
for small tumors, extending up to 2 cm in the CPA, necessitates temporal lobe retraction,
endangers the vein of Labb, and offers a restricted access to the CPA.
The retrosigmoid suboccipital approach offers an excellent panoramic visualization
of the whole CPA and increased safety during dissection from the brain stem and
lower cranial nerves (4,17-20). Facial and cochlear nerves can be identified both in
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their proximal (close to the brain stem) and lateral part (in the IAC), increasing the
chances for their preservation. The integrity of the facial nerve could be reconstructed,
if needed, in the CPA at the same surgery. With the approach hearing preservation can
be achieved even in large VS (19,20). Potential drawbacks of the approach are the need
of cerebellar retraction, the difficulty in visualizing the most lateral part of the IAC
without endangering the integrity of the inner ear, as well as the relatively higher rate of
postoperative headache. With current neuroanesthesia and some modifications of the
original retrosigmoid approach these disadvantages are rather theoretical.
When choosing the most appropriate surgical approach, factors such as tumor size,
extension in the IAC, preoperative hearing level, experience, and surgeon's preferences,
have to be taken into account. Excellent results have been achieved with each of these
techniques. Complete tumor removal is achieved in 80%- 99% (3,14,15,19,20) and
the recurrence rates are 0,5-5%. VS are benign tumors and their total tumor removal
leads to definite cure of the patient. The only exception to total removal is the attempt
to preserve function, as in patients with bilateral VS with real risk of deafness if good
preoperative hearing is available. The treatment goals could be best achieved using the
retrosigmoid approach.
Retrosigmoid approach:
The CPA is a triangular space formed by the superior and inferior limbs of the
cerebellopontine fissure. It is located posterior to the pyramid, inferior to the tentorium,
lateral to the pons, and ventrally to the cerebellum. The CPA is occupied by the CPA
cistern, which includes the trigeminal, abducent, facial, and vestibulocochlear nerves, the
superior cerebellar and anterior inferior cerebellar arteries, the flocculus of the cerebellum,
and the choroid plexus that protrudes through the foramen of Luschka (18). The facial
nerve exits the brain stem in the lateral part of the pontomedullary sulcus, 1-2mm
anterior to the entry zone of the vestibulocochlear nerve. In the CPA the facial and
cochlear nerves are usually displace anteriorly by the VS. The position of the nerves is
most constant in the lateral portion of the IAC: the facial and superior vestibular nerves
are above the transverse crest, with the facial nerve passing anterior. The cochlear
nerve is located anterior to the inferior vestibular nerve. The ninth, tenth, and eleventh
cranial nerves are located in the lower part of the cerebellopontine angle.
The neurophysiological monitoring throughout the whole procedure is an integral part
of each surgery. Monitoring of somatosensory evoked potentials is especially important
during patient positioning in order to identify spinal cord compression. At particular risk
are patients with degenerative cervical spine disease. The monitoring of auditory evoked
potentials is performed in case it is available. The functional integrity of the facial
nerve is monitored continuously by EMG transferred by loudspeakers.
The semi-sitting position has several major advantages: it allows the surgeon to
dissect the tumor bimanually; there is no need for constant suction; the continuous
irrigation of the operative field performed by the assistant obviates the need of coagulation
during tumor removal. The head is slightly flexed and rotated 30 degrees to the involved
side (Fig.1). Care must be taken not to occlude the venous jugular outflow or to
hyperflex or extend the cervical spine. The risks of this positioning - venous air embolism
308 Neuro-oncology
341
(up to 28%), paradoxic air embolism, tension pneumocephalus or circulatory instability

- are rather insignificant with adequate anesthesiological care. Transesophageal
echocardiography or monitoring of end- tidal carbon dioxide and precordial Doppler
echocardiography are the most specific method for venous air embolism detection.
Morbidity due to venous air embolism is similar in both the semisitting and supine
position and the choice of the position should be based on the surgical team preference.
A slightly curved skin incision medial to the mastoid process is done. A retrosigmoid
suboccipital craniectomy is performed using bone rongeurs, exposing the borders of the
sigmoid and transverse sinuses and extending to the floor of the posterior fossa. The
Fig. 1a
Fig. 1b
Fig. 1c
Fig. 1d
342 Skull Base
Fig. 1e
Fig. 1g
309
Fig. 1f
Fig. 1 Tumor extension grade according to the

INI (Samii) classification of VS. Fig.1a: Grade 1;
Fig.1b: Grade 2; Fig.1c: Grade 3a; Fig.1d: Grade
3b; Fig.1e: Grade T4a; Fig.1f: Grade T4b; Fig.1g:
Grade T5.
attempt to perform one-piece craniotomy with the highspeed drill is related to a
considerable risk of injury to the dura and sinuses. Special care should be directed
toward preservation of the mastoid emissary vein. Excessive traction to the vein could lead
to sinus laceration and increases the risk of venous air embolism.
The dura is incised in a curvilinear manner just 1,5-2 mm medial to the sagittal and
inferior to the transverse sinus (Fig.2). After slight elevation of the cerebellum, the
lateral cerebellomedullary cistern is opened and cerebrospinal fluid is allowed to drain.
Thus, the cerebellum relaxes away from the petrous bone. The intrameatal tumor
portion is exposed initially. The dura is stripped off from the posterior lip of the porus
and the posterior and superior walls of the IAC are drilled using decreasing sizes of
diamond drills under constant irrigation. The extent of IAC opening is tailored to the
extent of lateral tumor extension. The meatal dura is then incised and the intrameatal
tumor portion is carefully mobilized out of the IAC with a microdissector. The facial and
vestibulocochlear nerves are identified and the tumor is piecemeal removed (Fig.3). Then,
the extrameatal intracapsular tumor is debulked with the Cavitron ultrasonic aspirator
or a platelet- shaped knife. The dissection of the capsule from the surrounding neural
structures should begin only after adequate internal decompression is achieved. It is
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343
performed by strictly gripping the tumor capsule and dissecting in the level of the
arachnoid plane under continuous saline irrigation. Bipolar coagulation must be
reduced to a minimum and left up to the end of surgery for final hemostasis.
Once complete tumor removal is achieved, the continuity of the facial nerve can be
confirmed by its electrical stimulation (Fig.4). In case of nerve discontinuity, immediate
nerve reconstruction is performed at the same operation. The opened air cells in the
region of the IAC are occluded by placing pieces of fat tissue fixed with fibrin glue (Fig.5).
Jugular venous compression is performed at the end to make any opened or torn veins
visible for final hemostasis. Careful occlusion of the opened mastoid air cell with pieces
of fat tissue, sealed with fibrin glue decreases the risk of CSF leakage. Bone wax has to be
avoided, except for hemostasis if there is significant bleeding from the bone edges.
The skull base is reconstructed with methyl - methacrylate cranioplasty.
Fig. 2 The patient is in the semi-sitting position with the

head flexed and rotated slightly to the side of the tumor.
Fig. 3 The dura is incised along the transverse (TS) and

sigmoid sinuses (SS). Sufficient CSF is allowed to egress, the
retractor is put to protect the cerebellar hemisphere and the
tumor (Tu) is thus visualized.
Fig. 4 The IAC has been opened and the intrameatal tumor
portion partially removed. The distal part of the facial and
cochlear nerves are seen (*).
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311
Fig. 5 Complete tumor removal with preservation of the

integrity of the facial nerve (*). The intact trigeminal and
caudal cranial nerves are also seen.
Fig. 6 The IAC is plugged with fat pieces (F) and sealed with
fibrin glue.
Table 1 INI (Samii) classification of VS extension.

T1- purely intracanalicular VS
T2- intra- extrameatal
T3a - filling the CPA cistern
T3b - reaching the brain stem
T4a - compressing the brain stem
T4b - severe compression and dislocation of the brain stem and of fourth ventricle
T5- giant tumors (maximal diameter >4cm), extension over the midline.
*In case the VS has been previously treated with radiosurgery, this is designated with an
additional +R, e.g. Stage T4 A+R.
REFERENCES
1. Propp JM, McCarthy BJ, Davis FG, Preston-Martin S (2006) Descriptive epidemiology
of vestibular schwannomas. Neuro-oncology 8:1-11
2. Tos M, Stangerup SE, Caye-Thomasen P, Tos T, Thomsen J (2004) What is the real
incidence of vestibular schwannoma? Arch Otolaryngol Head Neck Surg 130:216-220
3. Briggs RJ, Fabinyi G, Kaye AH (2000). Current management of acoustic neuromas:
review of surgical approaches and outcomes. J Clin Neurosc 7:521-526
4. De Monte F., Al-Mefty O (1993). Neoplasms and the cranial nerves of the posterior fossa.
In: Barrow. DL (Ed.) Surgery of the cranial nerves of the posterior fossa. Park Ridge, IL:
American Association of Neurological Surgeons, 253- 234
312 Neuro-oncology
345
5. Sampath P, Rini D, Long DM: Microanatomical variations in the cerebellopontine

angle associated with vestibular schwannomas (acoustic neuromas): A retrospective study
of 1006 consecutive cases. J Neurosurg 92:70-78, 2000
6. Bakkouri WE, Kania RE, Guichard JP, Lot G, Herman P, Huy PT. Conservative
management of 386 cases of unilateral vestibular schwannoma: tumor growth and
consequences for treatment. J Neurosurg. 2009 Apr;110(4):662-9
7. Samii M, Matthies C (1997). Management of 1 000 vestibular schwannomas (acoustic
neuromas): surgical management and results with an emphasis on complications and
how to avoid them. Neurosurgery 40: 11-21.
8. Wilms G, Plets C, Goossens L, et al: Differentiation of Acoustic Neurinoma and
Meningioma Occurring Together in the Cerebellopontine Angle. Neurosurgery 30:443445, 1992
9. Brackmann DE, Green JD (1992). Translabyrinthine approach for acoustic tumor
removal. Otolaryngol Clin North Am 25:311-329.
10. Kondziolka D, Lunsford LD, Flickinger JC (2000). Gamma knife radiosurgery for
vestibular schwannomas. Neurosurg Clin North Am 11:651-658.
11. Lunsford LD, Niranjan A, Flickinger JC, et al: Radiosurgery of vestibular schwannomas:
summary of experience in 829 cases. J Neurosurg 102 Suppl:195-199, 2005
12. Iwai Y, Yamanaka K, Ishiguro T (2003). Surgery combined with radiosurgery of large
acoustic neuromas. Surg Neurol 59:283-289.
13. Day JD, Chen DA, Arriaga M: Translabyrinthine Approach for Acoustic Neuroma.
Neurosurgery 54: 391- 395, 2004
14. Lanman TH, Brackmann DE, Hitselberger WE, et al. (1999). Report of 190 consecutive
cases of large acoustic tumors /vestibular schwannoma/ removed via the translabyrinthine
approach. J Neurosurg 90:617-623
15. Gjuric M, Wigand ME, Wolf SR (2001). Enlarged middle fossa vestibular schwannoma
surgery: experience with 735 cases. Otol Neurotol 22:223-230.
16. Slattery WH, Brackmann DE, Hitselberger WE (1997). Middle fossa approach for
hearing preservation with acoustic neuromas Am J Otol 18:596-601.
17. Ciric I, Zhao JC, Rosenblatt S, et al: Suboccipital retrosigmoid approach for vestibular
schwannomas: facial nerve function and hearing preservation. Neurosurgery 56: 560-570,
2005
18. Rhoton AL, Jr (2000). The cerebellopontine angle and posterior fossa cranial nerves by
the retrosigmoid approach. Neurosurgery 47:S93-129.
19. Samii M, Matthies C: Management of 1000 vestibular schwannomas (acoustic
neuromas): Surgical management and results with an emphasis on complications and
how to avoid them. Neurosurgery 40:11-23, 1997.
20. Samii M, Gerganov V, Samii A (2006).Improved preservation of hearing and facial nerve
function in vestibular schwannoma surgery via the retrosigmoid approach in a series of
200 patients. J Neurosurg 105:527-535.
346
Maneuvers to prevent complications in

skull base surgery:
transpetrosal approach
Yoshinobu Seo, M.D.
Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
Key words: skull base surgery, transpetrosal approach, complication, cerebrospinal
fluid leak, petrosal vein, superior petrosal sinus
1. Introduction
Skull base surgery requires one of the most sophisticated techniques in neurosurgery.
Patients have mere symptoms despite their big tumor. We are supposed not to make
new symptoms and deteriorate patients performance status. It is important not only to
eliminate tumor but to preserve any functional structures. Watertight dural closure is
often impossible and cerebrospinal fluid (CSF) leak causes critical complications. The
procedure to prepare the vascularized flap and pack the dead space is also important
for preventing CSF leak. We introduce our techniques and maneuvers to prevent
complications in transpetrosal approach.
2. Diagnostic imaging
Cranial nerves and vessels can be detected preoperatively at some level. We have
to considerate which surgical approach is less invasive for critical structures. In these
days, the relationship between nerves, vessels and tumor can be well demonstrated
by three-dimensional computed tomographic angiography (3DCTA), diffusion tensor
image (DTI). The 3D-CTA depicts good relationship between the bone suture such as
parietomastoid suture, asterion and venous structures such as transverse-sigmoid sinus,
superior petrosal sinus (SPS), petrosal vein, sphenobasal vein, and sphenopetrosal vein
(Fig.1) 11,16). Dural incision and approach have to be decided to avoid obstructing their
venous drainage.
Gadolinium-enhanced constructive interference in the steady state image (GdCISS) is very useful to reveal the relationship between the tumor and nerves. Even
thin nerves around the tumor can be detected by DTI with a certain degree of level.
Only the trigeminal nerve, however, can be depicted in patients with a large tumor.
When the trigeminal nerve located at the medial side of the tumor, the tentorial artery
seems to be its main feeding artery. Bleeding decreases after detaching the tentorium
and the trigeminal nerve appears after tumor removal at the Meckels cave. When the
trigeminal nerve seats at the lateral side of the tumor, the ascending pharyngeal artery
is predicted as its main feeding artery. Resection of the tumor is more difficult because
the tumor has to be removed over the trigeminal nerve 6,9).
Maneuvers to prevent complications in skull base surgery: transpetrosal approach
347
It goes without saying that bone CT is useful to detect the high jugular bulb, air
cells around the semicircular canals and the petrous apex. It can also demonstrate the
relationship between the arcuate eminence and the superior semicircular canal, and the
petrous portion internal carotid artery and the cochlea 14, 15).
Fig. 1 a petroclival meningioma.

A,B: preoperative 3DCTA: Tumor is indicated by green. Venous
structure by blue. The petrosal vein contacting the tumor is well
demonstrated.
C: postoperative 3DCTA revealed the preserved petrosal vein.
D: preoperative Gd-enhanced MRI
E: postoperative Gd-enhanced MRI
F: DWI on the next day after operation
3. Skin incision and vascularized flap

Skin incision has to be planned to retain its vascular supply. We make a C-shaped
skin incision in combined transpetrosal approach with preservation of the superficial
temporal artery (STA) and occipital artery (OA) (Fig.2). STA may be needed when the
patient undergo STA-MCA bypass surgery in the future. Temporal musculofascia is
mainly fed by the middle temporal artery (MTA) which is a branch of STA 2, 3). There
is thick network of capillary blood vessels between the fascia and pericranium at the
distal part of the temporal muscle within 2cm in the distance. It is important not to
injure the capillary network and the origin of the MTA.
Dissection should be made under the galea aponeurotica at the temporal region,
and between the subcutaneous fat layer and the sternocleidomastoid muscle at the
occipital area. After inversion of the skin flap, the superficial temporal fascia is dissected
from the temporal muscle, with making the continuous membrane consisting of the
temporal fascia, the parietal pericranium, and the sternocleidomastoid muscle. The
temporal muscle is reflexed anteriorly, occipital muscles posteroinferiorly. Muscles are
not necessary to be cut, just folded back.
Fig. 2 C-shaped skin incision. STA: superficial

temporal artery, MTA: middle temporal artery,
OA: occipital artery
4. Craniotomy
Key hole surgery is cool. It, however, compromises safety. The term less invasive is
not for skull but for brain, nerves and vessels. Small craniotomy may cause temporal
lobe contusion with pressing at one point on the temporal lobe. It is important to dissect
the dura from the bone widely and elevate the temporal lobe in the middle cranial fossa
and retract it as a plane with large craniotomy.
348 Skull Base

Bone resection and drilling
In combined transpetrosal approach, it is faster to make L-shaped craniotomy
followed by mastoidectomy than the inverse sequence. Obtain the outer plate of the
mastoid, if possible. Exposure of the sigmoid sinus and the mastoid antrum makes it
easy to understand the anatomy at the early stage of the mastoidectomy. Utmost care
should be taken in drilling around the emissary veins and the protrusive sigmoid sinus
with egg shelling technique. After cutting the endolymphatic duct, peel off the dura of
the superior and posterior aspect of the petrous bone, which makes it facilitate to drill
around the semicircular canals. Skeletonization of the blue line of the superior and
posterior semicircular canals makes the working space wide. Fallopian canal begins
from at the mid-portion of the horizontal semicircular canals and on the extension line
of the short crus of the incus. Skeletonize the white connective tissue at the posterior
portion of the digastric ridge and follow it anteriorly around the stylomastoid foramen,
then you can find the inferior part of the fallopian canal. It is safe to remain the bony
shell around the fallopian canal with nerve stimulator at the level of 0.5-1.0mA.
Use a larger bur to drill the base of the middle cranial fossa to widen the working
space. The foramen spinosum can be found easily by following the middle meningeal
artery (MMA). Widen the foramen spinosum when the MMA is short to be cut.
Subsequently, skeletonize the foramen ovale and peel off the dura propria on the third
branch of the trigeminal nerve (V3, mandibular nerve). Anterior retraction of the V3
makes wide exposure of the petrous apex. It is safer not to peel off the dura propria at
the foramen ovale when the superficial middle cerebral vein (SMCV) drains mainly
around the foramen ovale as the sphenobasal veins. After elevation of the dura at the
superior aspect of the petrous bone, you can find the lesser petrosal nerve (LPN), then
the greater petrosal nerve (GPN) as bridging tissues between the bone and the dura.
After confirmation of the location of the geniculate ganglion with the nerve stimulator
at the level of 0.5-1.0mA, cut and elevate the dural propria and expose the GPN from
posterior to anterior.
Bleeding at the base of middle cranial fossa can be stopped by monopolar coagulation.
Use Surgicel and fibrin glue to get hemostasis around the GPN instead of coagulation.
The petrous apex often seems like double-deck and should be exposed widely. Drilling
starts from the petrous apex because there is nothing important structure in it.
It is said that the bony structure to remain is within 5mm from the geniculate
ganglion to protect the cochlea. It is useful, however, to understand the location of the
cochlea preoperatively with determination of the relationship between the cochlea and
the horizontal portion of the internal carotid artery (C6) by bone CT (Fig.3) 15). The
medial side of the C6 can be found under the GPN. In most cases, the bony structure to
be preserved is 2-3mm in the distance from the medial side of the C6.
Bone removal should be made to the posterior portion of the internal auditory canal.
After drilling, a small bone rongeur is useful to trim the bony edge. It is important to
drill the trigeminal impression as anterior as possible with elevation of the V3. Drilling
of the inferior part of the petrous bone is usually enough at the depth of the inferior
petrosal sinus (IPS). Use Surgicel and fibrin glue when bleeding occurs from the IPS
with avoiding the injury of the abducens nerve.
349
Fig. 3 Left: The distance between the medial tangent of petrous internal carotid artery (ICA) and
medial side of the basal turn of the cochlea.
Right: Illustrative drawing of superior view of middle cranial fossa. BB: Bills bar, Co: cochlea, GG:
geniculate ganglion, GPN: greater petrosal nerve, IAC: internal auditory canal, ICA: internal carotid
artery, MMA: middle meningeal artery, PA: petrous apex, PD: posterior fossa dura, SSC: superior
semicircular canal, V3: the third branch of the trigeminal nerve
5. Incision of dura mater and tentorium

The temporal dura should be cut as medial as possible to protect the temporal lobe with
the dura mater. Although dural sutures may be impossible in closing, vascularized flap
and free fat graft can prevent the cerebrospinal fluid leakage. When the sphenopetrosal
vein exists, dural incision should be made at its medial side.
The petrosal vein is often obstructed by big tumor and it can be sacrificed. It sometimes,
however, opens when tumors are small and medium sized, which can be revealed by
the 3D-CTA or susceptibility weighted image (SWI) (Fig.1). The opened petrosal vein
should be preserved because of some papers reporting hazardous complications after
injury of the petrosal vein 4,7,8,13,17). We have to keep in mind that any patient should not
be lost by venous congestion. When a tumor locates at the anterior part of the SPS, the
SPS flows toward posteriorly. In this situation, coagulation and cutting of the SPS at its
posterior portion makes the obstruction of the petrosal vein. Therefore, the tentorium
should be cut at the anterior to the petrosal vein 5,10).
Our dural incision is as follows (Fig.4): The First stage. Dural incision starts from
the anterior temporal region toward to the temporal base. Incision continues until just
lateral to the foramen ovale where the dura propria is already peeled off. You can confirm
the veins on the temporal lobe subdurally if you open the dura widely. The second
stage. Dural incision starts at just anterior to the transverse-sigmoid sinus junction and
superior to the SPS with care to the Labbe vein. Incision continues anteriorly which
is parallel to the SPS and connect the incision line of the first stage. The third stage.
Dural incision begins at the presigmoid posterior fossa dura and bends at the sinodural
angle anteriorly under the SPS. The dura is cut parallel and inferior to the SPS until the
anterior region to the petrosal vein. If you cannot see the petrosal vein, you can ensure
that when you reach the tumor locating anterior region to the petrosal vein. Then,
incision is connected to the first and second one. If the sphenopetrosal vein exists, the
incision of the superior region of the SPS is impossible. This dural incision makes wide
working space as same as the method of conventional dural incision with preserving
the petrosal venous flow.
The trochlear nerve may not be confirmed when tumor packed around the tentorial
incisula. The extension line of the posterior margin of the mandibular nerve is good
landmark to cut the tentorium. This line intersect at the tentorial incisula a couple of
millimeter posterior to the entrance of the trochlear nerve into the tentorium 1,12).
350 Skull Base

Fig. 4 Incision of the dura mater and the tentorium with
preservation of the petrosal vein and wide supratentorial working
space (left side).
When the trochlear nerve is not found by tumor, it is useful as
reference to use the extended line of the posterior edge of the
mandibular nerve intersecting at a couple millimeter posterior to
the entrance of the trochlear nerve into the tentorium.
C6: internal carotid artery, Co: cochlea, FO: foramen ovale, FS: foramen spinosum, GPN: greater
petrosal nerve, SPS: superior petrosal sinus, SS: sigmoid sinus, SCC:semicircular canals, TL: temporal
lobe, IV: trochlear nerve, V3: mandibular nerve,
6. Tumor resection
Tentorial incision at the early stage decreases the blood loss prominently. After
certain degree of internal decompression, resection of anterior part of tumor should be
done as soon as possible on purpose to decrease the feeding vessels. After protection of
the oculomotor nerve with cotton, posterior part of the tumor is removed.
Vessels on the tumor should be adjudged as normal vessels at first. Those often rotate
back to the brain. Tumor has some sort of membrane on it. Peel off the membrane in
company with vessels. Tumor surface is often bumpy. Utmost care has to be taken for
vessels which are usually located at the concaved indentation.
Blood should be washed out immediately with irrigation. Dry field should be always
kept to confirm the dissection plane and the normal structure. Suction irrigation is
very useful to wash out the blood. Use large sized sucker, or sucker would be choked
with tumor fragments. Non-stick bipolar forceps is necessary tool. Monitoring is also
useful to find nerves electrically.
Tumor often adheres firmly to the brain stem or cranial nerves, and vessels. If the
pia mater would not be preserved, tiny tumor should be left behind on the critical
structures.
7. Dural closure
After removing bone wax and other artificial materials, vascularized flap should be
placed directly on the mastoid antrum and the petrous apex with opened air cells.
Dural closure is usually impossible because the dural incision is very deep to be
sutured. Reed-shaped free fat strips are placed inside and outside of the dura mater
continuously. Fibrin glue is useful to fix the vascularized flap and fat grafts. Do not
pack the fat on the sigmoid sinus too much, or the sigmoid sinus would be obstructed.
Replace the outer plate of the mastoid bone or titanium mesh plate at the lateral surface
of the petrous bone.
8. Postoperative management
Height adjustment of continuous lumbar drainage is recommended 10 to 15cm above
the external auditory foramen. Continuous lumbar drainage after surgery is continued
351
for 3 days at longest. When days amount of the cerebrospinal fluid discharge is less
than 100ml, the lumbar drainage can be removed even within 3 days.
9. Conclusion
Gross total resection of tumors is recommended to prevent recurrence. However,
maintenance of postoperative performance status is the essential prerequisite. We
should exert efforts and ingenuity to prevent any complications.
References:
1. Abe H, Inoue T: Microsurgical Anatomy of the Cavernous Sinus. Jpn J Neurosurg
(Tokyo) 17: 656-665, 2008
2. Abul-Hassan HS, Ascher GD, Acland RD, et al: Surgical Anatomy and Blood Supply of
the Fascial Layers of the Temporal Region. Plast Reconstr Surg 77: 17-24, 1986
3. Casanova R, Cavalcante D, Grotting JC, et al: Anatomic basis for vascularized outertable calvarial bone grafts . Plast Reconstr Surg: 78:300-308,1986.
4. Distelmaier P: Complications of the operative neurosurgical treatment of trigeminal
neuralgia. Zentralbl Neurochir 37: 119-125, 1976
5. Goto T, Ohata K: Posterior clinoidal meningiomas. in Lee JH, Menigiomas. Springer,
2009, pp399-402
6. Ichimura S, Kawase T, Onozuka S, et al: Four subtypes of petroclival meningiomas:
differences in symptoms and operative findings using the anterior transpetrosal
approach. Acta Neuroschir (Wien) 150: 637-645, 2008
7. Inamasu J, Shiobara R, Kawase T, et al: Haemorrhagic venous infarction following the
posterior petrosal approach for acoustic neurinoma surgery: a report of two cases.
Euro Arch Otorhinolaryngol 259: 162-165, 2002
8. Koerbel A, Gharabaghi A, Safavi-Abbase S, et al: Venous complications following petrosal vein
sectioning in surgery of petrous apex meningiomas. Eur J Surg Oncol 35: 773-779, 2009
9. Kunii N, Ota T, Kin T, et al: Angiographic classification of tumor attachment of
meningiomas at the cerebellopontine angle. World Neurosurg 75: 114-121, 2011
10. Ohata K, Hara M: Petroclival meningioma. No Shinkei Geka. 30:1159-1171, 2002
11. Ozaki M, Seo Y, Hara K, et al: Anatomical Relationship between The Parietomastoid
Suture and Transverse Sinus: Evaluation by 3D Computed Tomographic Angiography.
Progress in Computed Imaging 31: 109-111, 2009
12. Rhoton AL JR: Anatomy and surgical approaches of the temporal bone and adjacent
areas. Neurosurg: 61(Suppl 4), 2007
13. Ryu H, Yamamoto S, Sugiyama K, et al: Neurovascular decompression for trigeminal
neuralgia in elderly patients. Neurol Med Chir (Tokyo) 39: 226-229, 1999
14. Seo Y, Ito T, Sasaki T, et al: Assessment of the anatomical relationship between the
arcuate eminence and superior semicircular canal by computed tomography. Neurol
Med Chir (Tokyo) 47: 335-340, 2007
15. Seo Y, Sasaki T, Nakamura H: Simple landmark for preservation of the cochlea when to
maximize bone drilling of the petrous apex through anterior transpetrosal approach.
Neurol Med Chir (Tokyo) 50: 301-305, 2010
16. Tanoue S, Kiyosue H, Okahara M, et al: Para-cavernous sinus venous structures:
Anatomical variations and pathologic conditions evaluated on fat-suppressed 3D fast
gradient-echo MR images. Am J Neuroradiol 27:1083-1089,2006
17. Tsukamoto H, Matsushima T, Fujiwara S, et al.: Peduncular hallucinosis following microvascular
decompression for trigeminal neuralgia: case report. Surg Neurol 40: 31-34, 1993

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Anatomical Basis of Skull Base Surgery:

Medical School of Pernambuco IMIP, Recife/Brazil

Key words: Skull Base Osteology, Microsurgical Anatomy

Anterior Skull Base

Middle Skull Base

Posterior Skull Base

Principles and practice of skull base

President - International Neuroscience Institute, Rudolf Pichlmayr Str. 4, 30625

Anterior and middle cranial base

Fig. 2 Extended endonasal endoscopic

The frontolateral approach

Fig. 3a frontolateral craniotomy.

Fig.3b a meningioma (Tu) arising from the anterior clinoid

Fig. 3c complete tumor removal with preservation of the

Cerebellopontine angle and Petroclival area

Retrosigmoid- suprameatal approach (Samii`s approach)

Fig. 4a Foramen magnum meningioma, exposed via a retrosigmoid craniectomy

should be opened wide.

Basic principles of contemporary

Preoperative studies and surgical planning

272 Skull Base

The frontotemporal approach

274 Skull Base

Endoscope assisted technique

The retrosigmoid approach

276 Skull Base

Endoscope assisted technique

The far lateral approach

278 Skull Base

Endoscope assisted technique

of this approach(3, 11, 12).

280 Skull Base

Endoscope assisted technique

5. Bertalanffy H, Gilsbach JM, Mayfrank L, Klein HM, Kawase T, Seeger W. Microsurgical

Microsurgical treatment of Olfactory

Fig. 1 Head position in LSO approach

Fig. 2 Skin incision in performing a left LSO approach.

Fig. 3 One burr hole and the craniotomy in a

Removal of OGM through LSO

Differences between LSO, pterional, bifrontal, frontoorbital approaches

dissection of the A2 branches and the posterior part of the tumor.

15. Nagy L, Ishii K, Karatas A, Shen H, Vajda J, Niemela M, Jaaskelainen J, Hernesniemi J,

Surgical Treatment of Complex Tumors

DIAGNOSTIC EVALUATION OF THE ANTERIOR SKULL BASE

SURGICAL APPROACHES: THE TRANSBASAL-TRANSFRONTAL

Scalp and soft tissue

Fig. 1 Exposition of the

Craniotomy and skull base osteotomies

Fig. 2 A: Bifrontal craniotomy and fronto-orbital osteotomy. The bifrontal craniotomy is

Fig. 3 Lines of cutting at

Fig. 4 Recurrent low grade sarcoma.

Clivectomy and posterior fossa involvement

Fig. 8 Simultaneous extra and intradural invasion of the neurovascular

Fig. 9 Clival chordoma. Sagital MRI showing the hour-glass growing at

Modifications of the technique. Complementary approaches

Fig. 11 Nasopharyngeal Juvenile Angiofibroma. Involvement of anterior fossa with

Fig. 12 Same patient of figure 12. Total

Fig. 14 Steps of the reconstruction

Fig. 15 Pneumonia in the postoperative

Craniotomy and clinoidectomy

One point memo