Review of an 11year experience in retrosigmoid approach. Air cells at this level can be opened during the drilling and should also be waxed to prevent csf leakage. The suboccipital lateral or retrosigmoid approach is the main neurosurgical approach to the cerebellopontine angle cpa. After anterior elevation of the scalp and associated muscles, retrosigmoid craniotomy was. Madison michael, ii2,3 1college of medicine, universityof tennesseehealthsciencecenter, memphis, tennessee, united states 2department of neurosurgery, university of tennessee health science center, memphis, tennessee, united states. Surgical exposure gained in an extended retrosigmoid approach. The retrosigmoid or lateral suboccipital approach is the most commonly used approach and is also indicated for tumors of all sizes, particularly when hearing preservation is the goal. Retrosigmoid approach augusta university research profiles. In this video, we aimed to demonstrate retrosigmoid transtentorial resection of a 4. Permission granted for nonprofit educational use of images, with attribution to their source. The keyhole retrosigmoid approach is a versatile one.
Dr silverstein reported an overall 93% success rate for relief of vertigo. Extended approach with removal of bone over the sigmoid sinus. Retrosigmoid approach to the posterior and middle fossa. Underlay hourglassshaped autologous pericranium duraplasty in keyhole retrosigmoid approach surgery. The retrosigmoid approach is widely used to access the cpa, most commonly for the resection of schwannomas or meningiomas. Retrosigmoid approach to vestibular schwannomas sciencedirect. The keyhole retrosigmoid approach to the cerebellopontine. Sep 20, 2019 anatomical delineation of a safety zone for drilling the internal acoustic meatus during surgery for vestibular schwanomma by retrosigmoid suboccipital approach.
Establish the versatility and usefulness of the keyhole retrosigmoid approach to the cerebellopontine angle cpa in various pathologies. Combined subtemporal and retrosigmoid keyhole approach for extensive petroclival meningiomas surgery. Nov 12, 2017 the retrosigmoid craniotomy is a modification of the traditional suboccipital craniotomy, which was first described in the literature by frankel et al. The transmastoid retrosigmoid approach increases the exposure and gives better access to the cpa targets. Use our online service to convert pdf to ppt in a heartbeat. Frontal bilateral remodelling with frontalorbital bandeau. Pdf the retrosigmoid approach is a workhorse approach to the cerebellopontine angle cpa, providing access from the foremen magnum to the tentorium. Most neurologic and otologic surgeons are familiar with the procedure and have worked out their own particularities. In cases of mild or moderate involvement we do not perform nasal osteotomies because the deviation of the nasal axis improves after frontoorbital advancement.
Retrosigmoid craniotomy for microvascular decompression. This approach constitutes the most direct approach to the midclival region, prepontine cistern, and brainstem and follows the traditional principles of skull base surgery. It is not necessary to reveal the entire transverse or sigmoid sinus, but seeing their edges is an indication that an adequate intradural exposure can be obtained. Position the retrosigmoid approach can be performed with the patient in the sitting, parkbench, lateral or supine position with the head rotated maximally to the contralateral side. The space created after drilling the suprameatal tubercle and the bone medial to the internal auditory canal and below the trigeminal nerve was enough to extend the retrosigmoid approach as far as.
The technical tip we propose for dural closure after retrosigmoid approach is to insert a layer of autologous pericranium harvested during the opening step as an underlay hourglassshaped plug, larger than the defect, under the dural plane, and to stitch it with an insidetooutside direction to the dura mater. The retrosigmoid approach is indicated for access to lesions of the lateral posterior fossa and lateral skull base from the level of the tentorium to the level of the. Retrosigmoid suprafloccular transhorizontal fissure approach. It also provides the demographics, presenting features and the. Retrosigmoid transtentorial resection of a petroclival. This patient had a previously ruptured aica aneurysm in the meatal region for which a retrosigmoid approach was selected.
The suboccipital approach is performed by a neurosurgeon. Retrosigmoid approach to tumors of the cerebellopontine angle. This study was conducted to determine whether removing the bony prominence located above the porus of the internal acoustic meatus, called the suprameatal tubercle, and surrounding bone using the retrosigmoid approach would aid in the exposure of tumors that are located predominantly in the cerebellopontine angle but. Vestibular schwannomas vss, also called acoustic neuromas, account for 8% to 10% of intracranial neoplasms. Retrosigmoid transmeatal approach an anatomic study of an approach used for preservation of hearing in acoustic neuroma surgery and vestibular neurotomy j. Jho prefers a retromastoid or retrosigmoid approach for acoustic tumor surgery because it results in high probability of the preservation of the facial nerve and hearing nerve functions. This approach may be utilized to manage tumors of the lateral posterior fossa and to perform microvascular cranial.
Retrosigmoid approach to the posterior and middle fossae. In this procedure, a careful dissection of the tumor within the arachnoid plane from the neurovascular structures is described. More specifically, they account for more than 80% of the cerebellopontine cp angle tumors, making them the most comm. Surgical approaches for resection of acoustic neuromas. Surface anatomy of the posterolateral cranium regarding the localization of the initial burrhole. Suprajugular extension of the retrosigmoid approach. During drilling, extensive irrigation is used to avoid any thermal damage to the nerves in the canal. The translabyrinthine and retrosigmoid remain significant approaches in the surgical excision of acoustic schwanomma. The retrosigmoid approach for the microsurgical removal of an acoustic neuroma vestibular schwannoma is described, and perioperative medical.
Of these, the retrosigmoid lateral suboccipital approach lsa is the most convenient and frequently used. The retrosigmoid approach is a hearingpreserving operation that is used for tumors with mainly extracanalicular extension into the cpa and minimal extension into the iac. Retrosigmoid approach operative techniques in otolaryngology. Retrosigmoid approach for resection of petroclival. Jugular foramen tumors often extend intra and extracranially. Retrosigmoid craniotomy often called keyhole craniotomy is a minimallyinvasive surgical procedure performed to remove brain tumors.
It can be used to deal with different pathologies through a unified access, and with the increasing exclusive use of endoscopes, a truly minimally invasive surgery can be achieved. Retrosigmoid clip anterior inferior cerebellar artery. Lesions lateral to the meatus can be approached via a retrosigmoid or far lateral approach. The extended retrosigmoid approach for neoplastic lesions in the posterior fossa. This approach provides direct access to the lateral cerebellar hemisphere, cerebellopontine angle, and lateral skull base, including the posterior petrous bone. The internal auditory canal can be accessed through different surgical approaches based on different trajectories. The limitations of the transmeatal phase of the retrosigmoid transmeatal approach are shown, and the problems of opening the internal acoustic meatus via this approach and the criteria for its use are discussed. Retrosigmoid approach to tumors of the cerebellopontine. The number of complications was higher in the group of reoperated patients mri in a pfeiffer syndrome patient before treatment. The unilateral suboccipital approach was popularized by woolsey and with great contributions by fedor krause after several refinements and modifications through different dedicated neurosurgeons fish, house and seiffert, dandys suboccipital approach with an ipsilateral suboccipital flap evolved to the retrosigmoid transmeatal approach. The anatomic exposure of the posterior fossa provided by the retrosigmoid approach is bounded superiorly by the tentorium cerebelli and inferiorly by the jugular foramen and foramen magnum. Imageguided, endoscopicassisted drilling and exposure of the whole length of the internal auditory canal and its fundus with preservation of the integrity of the labyrinth using a retrosigmoid approach. Objective to validate the usefulness of partial mastoidectomy in the retrosigmoid approach and to evaluate the complications of this maneuver.
The abcs of measuring intracerebral hemorrhage volumes. Transmastoid retrosigmoid approach to the cerebellopontine. Retrosigmoid craniotomy and its variants springerlink. This article describes the progressive widening of the posterior trajectory that begins with progressive drilling of the petrous bone the retrosigmoid approach. Use of the retrosigmoid suprafloccular transhorizontal fissure approach in cadaveric heads confirmed the extent of exposure. The patient was placed in parkbench position and a leftsided suboccipital craniotomy was performed. Because each patient and each acoustic neuroma is unique, it is important to seek treatment at a center that offers the full range of options, including surgery, radiation, and hearing rehabilitation. Mastronardi l, cacciotti g, caputi f, roperto r, tonelli mp, carpineta e, fukushima t. The approach described here is a useful modification of the retrosigmoid approach, which allows resection of large petroclival tumors without the need for supratentorial craniotomies.
Lateral suboccipital approach retrosigmoid springerlink. The retrosigmoid suprajugular approach provides a lessaggressive approach for a subset of tumors of the jugular foramen. A stepwise illustration of the retrosigmoid approach for resection of a. The head was placed in the fukushima lateral position, 12 and a cshaped or curvilinear incision was made. Eventually, small oblique incisions are accomplished to increase surgical exposure 3, 2 and 4 tackup dural sutures for enhancement of the surgical view courtesy of prof. Use pdf download to do whatever you like with pdf files on the web and regain control. The output powerpoint presentation will retain its original formatting, for you to revise and edit. In four easy steps, you can make acrobat dc or acrobat reader dc your default pdf program. A team approach between a neurotologist and a neurosurgeon offers the patient the expertise of both specialties and maximizes the chances for an optimal outcome. Pdf transmastoid retrosigmoid approach to the cerebellopontine.
Suboccipital surgery for acoustic neuroma cincinnati, ohio. Although technically meticulous, this approach is not timeconsuming. A new method of patients head positioning in suboccipital retrosigmoid approach ersin erdogan 1, erdinc civelek 1, mehmet bulent onal 1, ilker solmaz 1, cahit kural 1, hakan yakupoglu 2 1 department of neurosurgery, gulhane military medical academy, 06100 etlik, turkey 2 medicana ankara hospital 06200, cankaya ankara, turkey. Retrosigmoid intradural suprameatal approach to meckels cave. How to make acrobat reader dc or acrobat dc your default pdf program watch a short video tutorial below on how to set acrobat reader. Retrosigmoid intradural suprameatal approach to meckels cave and the middle fossa. All children received at least two doses of antipneumococcal vaccine.
Microsoft edge is the default program for opening pdf files on windows 10. Retrosigmoid approach to vestibular nerve section jama. Pdf this video describes the classic retrosigmoid approach for the resection of petroclival lesions. The retrosigmoid approach is a common route to the cerebellopontine angle and lateral clivus. It is mainly used in the treatment of cpa tumors and vascular decompression of cranial nerves. Retromastoid craniotomy the neurosurgical atlas, by. Indications for this approach are variable such as resection of meningiomas, acoustic neuromas and epidermoid tumors, treatment of vascular lesions of. Retrosigmoid approach to vestibular schwannomas aaron a. Retrosigmoid suprafloccular transhorizontal fissure approach for resection of brainstem. A stepwise illustration of the retrosigmoid approach for. A prospective study using navigation registered with anatomical landmarks in order to identify the transverse and sigmoid sinuses junction tssj was carried out in a.
The retrosigmoid approach offers a more favorable angle of view into the cerebellopontine angle cpa and a markedly reduced need for cerebellar retraction than does the classic suboccipital approach. Description of retromastoid craniotomy workhorse for infratentorial approaches to the cerebellopontine angle. We could not find publications for the use of the resection of the suprameatal tubercle in the retrosigmoid approach for microvascular decompression of the trigeminal neuralgia. Keyhole brain surgery minimallyinvasive retrosigmoid. Retrosigmoid approach for resection of cerebellopontine angle meningioma and decompression of the trigeminal nerve. The retrosigmoid approach is a powerful approach to lesions of. The cerebellopontine angle cpa is the seat of different pathologies. After anterior elevation of the scalp and associated muscles, retrosigmoid craniotomy.
Primary dural closure for retrosigmoid approaches garrett t. The purpose of this study was to prove the use of polyesterurethane as a dural graft material and to inform the postoperative results. Retrosigmoid transmeatal approach europe pmc article. Aug 06, 2016 the retrosigmoid approach offers a panoramic view of the cpa. Retrosigmoid approach definition of retrosigmoid approach.
Several approaches to lesions in the cerebellopontine angle cpa have been employed 3, 10, 11, 14, 19, 21, 22, 25. Vestibular nerve section via retrosigmoid craniotomy. After careful exploration of the trigeminal root entry zone, the offending vessel is identified and moved away. Transmastoid retrosigmoid approach to the cerebellopontine angle. One of the advantages of retrosigmoid approach is that it provides a good exposure to the cranial nerve, brainstem. Following, extended retrosigmoid approach was performed.
The cerebellopontine angle is located between the superior and inferior limbs of the cerebellopontine fissure, an angular cleft formed by the petrosal cerebella. Surgical removal remains one of the key treatment modalities for vestibular schwannomas. Jun 14, 2019 role of craniotomy repair in reducing postoperative headaches after a retrosigmoid approach. The dural opening is made in cruciate fashion with two of the leaflets based on the transverse and sigmoid sinuses. Since the first description of the unilateral approach to the cerebellopontine angle cpa in 1903 by fedor krause 22, 23, several techniques were developed by cushing 7, seiffert 47, dandy 810, house 18, 19, and fisch among others in order to access the cpa structures. The neurosurgical as well as otologic component of the tumour begs for a standardized protocol for its management and surgical approach. Endoscopic skull base surgery chap 9, the fully endoscopic retrosigmoid approach by hrayr k.
However, only the medial two thirds of the internal auditory canal iac can be reliably exposed without damaging the otic capsule. Full text full text is available as a scanned copy of the original print version. The operation was performed via a middle fossa approach in 20 cases, via the retrolabyrinthine approach in 65 cases, and via a retrosigmoid, suboccipital approach in six recent cases. Neurosurgeons may use this approach to reach certain tumors, such as. The grosstotal removal of tumors located both intracranially and intraforaminally is technically challenging and often requires a combined skull base approach. N2 the retrosigmoid approach is an ideal approach for lateral posterior fossa pathology. Infratentiorial approach verse a retrosigmoid approach. Resection of a large acoustic neuroma through the retrosigmoid approach. This approach plays a small role in the resection of acoustic neuromas. The vestibular neurectomy by retrosigmoid approach. Suprameatal extension of the retrosigmoid approach. A retromastoid approach is made with an approximately oneinch or threecm skull opening via a twoinch or fivecm skin incision behind the ear. In 12 of the 95 cases, the standard retrosigmoid approach was extended to allow additional exposure of the middle fossa through meckels cave, which constituted the risa.
Infratentorial approach is the approach performed beneath the tentorium of the cerebellum where as the retrosigmoid approach is suboccipital approach involving removal of a portion of the bone behind the ear. Associate pdf files to always open in reader or acrobat on. Department of neurosurgery, tufts medical center and tufts university school of medicine, boston, massachusetts epidermoid cysts are rare lesions accounting for 1%. An assessment of complications and payments in a longitudinal administrative database. Twentynine cases of resection of suprasellar meningioma through small bone window. In this videoabstract, we present a one burrhole craniotomy for the upper retrosigmoid approach developed in helsinki neurosurgery to access the lateral cerebellar hemisphere, the cerebellopontine angle, and lateral skull base e. An endoscopic assisted retrosigmoid approach to the. Illustrations of skull base surgery and neurotology. Suprameatal extension of retrosigmoid approach for.
Oxidized regenerated cellulose is used to keep the vessel in its new position far from the nerve. Includes details on clinical presentation, evaluation, and indications of surgery. Depending on presenting symptoms, tumor size, and age of the patient, the options include observation, surgical resection, and radiosurgery. A new method of patients head positioning in suboccipital. Preventing or treating deafness in both ears for people with nf2 requires a team approach. Review of an 11year experience in retrosigmoid approach for. Surgical approaches for resection of vestibular schwannomas. We described the retrosigmoid suprajugular approach with its advantages, caveats, and indications. Indications for the retrosigmoid approach are summarized in table 5. Retrosigmoid suprafloccular transhorizontal fissure. This approach alleviates cerebellar retraction, facilitates surgery in the supine position, promotes the use of the endoscope, and is associated with negligible complications.
However, the addition of a suprameatal extension significantly improved the surgical freedom provided by the retrosigmoid approach. Combined pre and retrosigmoid approach for petroclival meningiomas with the aid of a rotatable head frame. The retrosigmoid approach offers an excellent exposure of the brainstem and cranial nerves iv through xii. This procedure allows for the removal of skull base tumors through a small incision behind the ear, providing access to the cerebellum and brainstem. The traditional suboccipital craniotomy in the retrosigmoid approach gives limited exposure to the cerebellopontine angle cpa structures and necessitates cerebellar retraction, whereas the addition of drilling of the mastoid process with. Facial nerve function after excision of large acoustic neuromas via the suboccipital retrosigmoid approach. Hearing preservation in crandotomia removal of intracanalicular acoustic neuromas via the retrosigmoid approach. We describe here the surgical technique and results of this approach.
Imageguided surgical planning using anatomical landmarks. Patients head positioning just before the operation is crucial to perform the procedure effectively and safely. The suprameatal extension of this approach has been described for other purposes, especially in tumors invading meckels cave resection. Dec 31, 2019 combined pre and retrosigmoid approach for petroclival meningiomas with the aid of a rotatable head frame. Although the postoperative facial nerve function results were better in the group of patients whose mediumsized tumors were removed through the tl approach compared with patients operated through the rs approach, the difference between these 2 groups was not statistically significant enough to favor one approach over the other. Underlay hourglassshaped autologous pericranium duraplasty. Retrosigmoid approach to acoustic neuroma vestibular.
A translabyrinthine vs retrosigmoid approach to acoustic. The authors present background of the retrosigmoid approach, surgical steps. Ab the retrosigmoid approach is an ideal approach for lateral posterior fossa pathology. Retrosigmoid versus translabyrinthine approach for acoustic neuroma resection. Mar 10, 2020 technical pearls for performance of a retrosigmoid approach for vestibular schwannoma. Retrosigmoid intradural suprameatal approach to meckel s. It can be used to deal with different pathologies through a. Multiple approaches have been developed to permit the surgeon to tailor the procedure to a particular patients pathology and physiological status. Web to pdf convert any web pages to highquality pdf files. The retrosigmoid rs approach offers identification of the facial nerve at the brainstem with possible preservation of hearing. Hearing conservation in acoustic neurilemmoma surgery via the retrosigmoid approach. Though both the approaches are different, they can be used for excision of tumor cerebellopontine angle tumor.
Madison michael, ii2,3 1college of medicine, universityof tennesseehealthsciencecenter, memphis, tennessee, united states. Ebersold, md the treatment of vestibular schwannomas has evolved and changed. A samiib2 glossopharyngeal nerve schwannoma is shown to exemplify the procedure. Superiorly, bone is removed up to the inferior margin of the transverse sinus. The retrosigmoid suprameatal approach allows for adequate brainstem decompression. The approach involved locating the aica distally and tracking it proximally to the origin off the basilar artery.
This study presents a suprajugular extension of the retrosigmoid approach directed through the osseous roof of the jugular foramen that allows the removal of tumors located in the cerebellopontine angle with extension into the upper part of the foramen, with demonstration of an illustrative case. Schematic view of retrosigmoid approach showing the cshaped dural flap 1 and the tackup sutures 5. In the retrosigmoid approach, the anterior limit of the dissection is the sigmoid sinus. Retrosigmoid approach the neurosurgical atlas, by aaron. An endoscopic assisted retrosigmoid approach to the cerebellopontine angle for resection of an epidermoid cyst mina g. The retrosigmoid suprajugular approach provides an excellent option for tumors with a. A suprajugular extension of the retrosigmoid approach has recently been proposed for dealing with intracranial tumors with minimal extension into the jugular foramen.
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