Abstract
Evacuation of middle fossa trigeminal schwannomas (TS) warrants a subtemporal interdural approach through the lateral wall of the cavernous sinus (CS). The dura comprises the dura propria, which follows the trigeminal nerve and develops into the epineurium, and periosteal layer. The interdural approach involves peeling off the dura propria and exposing the epineural sheath. The venous route around the CS is often obstructed due to TS progression. The interdural approach based on venous route preservation remains to be discussed. The laterocavernous sinus (LCS) is formed in these layers, draining to either the medial or lateral route. In the lateral route, the LCS drains to the pterygoid plexus via the middle cranial fossa foramen. Exposure of the interdural space disturbs the lateral route’s venous flow. We describe an operative strategy for venous route preservation in TS via the LCS lateral route. The venous route can be preserved by peeling off the dura propria from the posterior end of the foramen ovale short of the venous drainage route to the pterygoid plexus epidurally and then cutting from the middle cranial fossa dura posterior to the venous route subdurally to the exposed interdural space. This technique helps in avoiding postoperative venous complications.
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All authors contributed to the study concept and design. Material preparation, data collection, and analysis were performed by Kazuhide Adachi, Mituhiro Hasegawa, and Yuichi Hirose. The first draft of the manuscript was written by Kazuhide Adachi, and all authors commented on the early versions of the manuscript. All authors read and approved the final manuscript.
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Operation video (Case 3). Following frontotemporal craniotomy, the middle meningeal artery was cauterized and cut at the foramen spinosum. Kawase’s triangle had already undergone osteolysis for tumor compression. First, the greater superficial petrosal nerve was preserved in the subperiosteal layer, and then the periosteal dura was peeled off from the foramen ovale to the superior orbital fissure depending on the tumor size. However, this maneuver disturbs the venous flow; therefore, we stopped just short of the foramen rotundum. The posterior fossa dura was opened, and a part of the trigeminal schwannoma within the posterior fossa was exposed. A cut was made from the middle cranial fossa dura posterior to the superficial middle cerebral vein and onwards to the exposed interdural space. The superficial middle cerebral vein was running in the interdural space. The perineural sheath of the trigeminal nerve in the interdural space and the cutline of the middle cranial fossa were connected. The dura propria was cut along the lateral side of the tumor. The fanning trigeminal nerve was located outside the tumor. The cerebrum tentorium was cut to expose the tumor. The fanning trigeminal nerve was separated from the tumor, and the tumor was removed. A final view of this operation is provided. The fanning trigeminal nerve remained, and the tumor was removed (MP4 292225 kb)
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Adachi, K., Hasegawa, M. & Hirose, Y. Epidural and subdural interdural approach to the lateral wall of the cavernous sinus for preserving the laterocavernous sinus in trigeminal schwannoma. Neurosurg Rev 46, 27 (2023). https://doi.org/10.1007/s10143-022-01934-w
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DOI: https://doi.org/10.1007/s10143-022-01934-w