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Anatomy of the superior petrosal veins and their exposure and management during petrous apex meningioma surgery using the lateral suboccipital retrosigmoid approach

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Abstract

During surgeries in the upper cerebellopontine angle (CPA), the superior petrosal veins (SPVs) often act as obstacles; and their sectioning sometimes causes serious complications. In this study, we introduced a classification system for the SPVs wherein their tributaries were classified into four groups on the basis of their courses and draining areas. We furthermore explained the detailed anatomy of the vein of the cerebellopontine fissure, which is the largest tributary. In surgeries of petrous apex meningioma, the knowledge of the displacement pattern of the vein is very helpful for avoiding major venous complications. Therefore, we elucidated its anatomical situation in relation to the original portion of the meningioma and the natural draining point of the vein into the superior petrosal sinus (SPS) in each patient. In addition, we described the methods and techniques used to expose and manage the vein of the cerebellopontine fissure during surgery using the lateral suboccipital retrosigmoid approach. Presenting two illustrative cases, we recommend that the initial exposure of the tumor should be performed through the infratentorial lateral supracerebellar route and that the suprafloccular cistern is the best area to find the vein of the cerebellopontine fissure. We emphasized the importance of the preservation of the vein of the cerebellopontine fissure and also proposed the order for exposure of SPV tributaries during upper CPA surgery using the retrosigmoid approach.

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Acknowledgments

We would like to express our gratitude to Prof. Rhoton, University of Florida, for giving us the opportunity to study the microsurgical anatomy of the veins of the posterior fossa. We also thank Ms. Takako Shiga and Ms. Sumiko Matsushima for assisting in preparing this manuscript and illustrations.

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Authors and Affiliations

  1. Department of Neurosurgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga-shi, Saga, 849-8501, Japan

    Toshio Matsushima, Masatou Kawashima & Kohei Inoue

  2. Department of Neurological Surgery, University of Florida, Gainesville, FL, USA

    Ken Matsushima

Authors
  1. Toshio Matsushima
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  2. Masatou Kawashima
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  3. Kohei Inoue
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  4. Ken Matsushima
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Correspondence to Toshio Matsushima.

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Comments

Andrei Koerbel, Joinville, Brazil

This manuscript provides an interesting review on the petrosal vein drainage pathways, their relationship with petrous apex meningiomas and the risks of sacrificing these veins. The topic is very important, since the risks of sacrificing the petrosal veins have been underestimated by many neurosurgeons. The most usual relationships of petrous apex tumors with petrosal vein complexes should be known by neurosurgeons that treat these lesions. Thus, these interconnections should be taken in consideration to choose the safest surgical strategy.

Some intraoperative maneuvers may increase the rates of petrosal vein preservation in petrous apex meningiomas. In my experience, the intraoperative management of the spatula for cerebellar retraction is the most important issue. When the spatula is positioned on the cerebellar surface, the direction of the retraction is essential. The cerebellar retraction may cause a vein rupture, mainly if the traction is applied on the superolateral cerebellar surface to the inferior or medial direction. If the traction is applied on the inferolateral cerebellar surface to medial-superior direction, tension on the superior petrosal veins is avoided. This procedure allows exposing the petrous apex without stretching the superior petrosal vein complex. The other maneuvers described by the authors are meaningful and may be used according to specific situations. However, in most cases, the safest strategy is to avoid stretching the superior petrosal veins during cerebellar retraction.

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Feng Xu and Nicholas Bambakidis, Cleveland, USA

The venous drainage system of the superior petrosal vein (SPVs) has received increasing attention during surgery in the upper cerebellopontine angle. Preservation of the SPVs should be attempted whenever possible to minimize the risk of venous complications such as cerebellar and brainstem edema and hemorrhagic infarction. The authors depict the anatomy of SPVs tributaries and the impact of surgical manipulation during petrous epex meningioma resection using the lateral subocciptal retrosigmoid approach. The authors nicely demonstrated the suprafollicular cistern as a landmark to identify the vein of cerebellopontine fissure in the infratentorial lateral supracerebellar route. We agree that the angioarchitecture of cerebellopontine-cerebellomedullary veins described in petrous meningioma surgery is more complex compared to anatomy of microvascular decompression, as there are no major venous channel displacements (depending on the origin, axis or direction of tumor growth and effect of local vascularity of tumor mass itself) in the latter. The vein of cerebellomesencphalic fissure and the common stem of SPVs should be preserved, whereas the tributaries of the tentorial cerebellar surface draining group might be sacrificed under certain circumstances.

The infratentorial lateral supracerebellar approach described in the article is best suited for petroclival miningiomas located mainly in the posterior fossa with less extension into the middle fossa. In the lateral supracerebellar transtentorial approach, the tentorial medial to the trigeminal nerve is incised toward the free edge, which improves exposure to the petroclival area and permits free access to the middle fossa. When the tumor has a larger supratentorial extension, one stage tumor remover through the transpetrosal approach or a two-stage surgery combining retrosigmoid suprameatal and frontotemporal approaches might be selected.

We find that in such cases (large tumors medial to the internal auditory canal with both middle and posterior fossa extension) that a combined transpetrosal approach is best considered. In these cases, splitting of the tentorium to access the middle fossa tumor component necessitates division of the SPV. Careful attention to the overall venous pattern of drainage is thus required during preoperative surgical assessment.

References

1. Xu F, Karampelas I, Megerian CA, Selman WR, Bambakidis NC. Petroclival meningiomas—an update on surgical approaches, decision making, and treatment results. Neurosurg Focus 2013 Dec;35(6):E11

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Tiit Mathiesen, Stockholm, Sweden

A group of very experienced surgeons extended the meningioma society meetings with meetings “on the cerebral venous system”. With time, I think I have realized why this was realized by renowed, experienced microsurgeons. Unexpected and uncommon complications are the most common remaing complications, when skill and experience has done away with “beginners mistakes”—and venous complications can be very treacherous and unpredictable.

The cerebellar drainage system has a fair degree of variability, and routine sacrifice of major draining veins such as the superior petrosal vein, vermian veins and tentorial draining veins can frequently—but not always—be done with impunity. Experienced surgeons cite complications from ssacrifice of the petrosal vein; we recently published a nearly fatal cerebellar venous infarct from sacrifice of one (!) cerebellar draining vein. Sacrifice of normal structures to improve exposure is one way to increase safety, but knowledge of risk with such maneuvers is indispensable unless we are prepare to accept a random risk of serious venous complications. Professor Matsushima has devoted a large part of his professional carreer to the meticulous study of surgical anatomy, especially of the posterior fossa. I am grateful for this opportunity to get a more profound understanding of his surgical concepts, that are firmly rooted in the respect of normal anatomy and strive for excellent outcomes.

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Matsushima, T., Kawashima, M., Inoue, K. et al. Anatomy of the superior petrosal veins and their exposure and management during petrous apex meningioma surgery using the lateral suboccipital retrosigmoid approach. Neurosurg Rev 37, 535–546 (2014). https://doi.org/10.1007/s10143-014-0548-4

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