Abstract
Background
The retrochiasmatic region is one of the most challenging areas to surgically expose. The authors evaluated the transcrusal approach, which involves removal of the superior and posterior semicircular canal from the ampulla to the common crus, to expose the retrochiasmatic region and compared it with the retrolabyrinthine approach, both of which are a variation of the posterior petrosal approach with hearing preservation, with a special emphasis on the influence of temporal lobe retraction.
Methods
Six sides of silicone-injected cadaveric heads were dissected using two approaches: the transcrusal approach and the retrolabyrinthine approach. For each craniotomy, 3 exposure parameters in the retrochiasmatic region were measured: (1) horizontal distance, (2) vertical distance, and (3) triangular area of exposure, at three different levels of temporal lobe retractions: 0, 5, and 10 mm of retraction from the level of the tentorial incisura.
Results
Without temporal lobe retraction, only the transcrusal and not the retrolabyrinthine approach provided a direct exposure of the retrochiasmatic region, especially in the horizontal distance (p < 0.001). At all levels of temporal lobe retraction, the transcrusal approach provided greater exposure in the horizontal and vertical distances and in the area of exposure. Nonetheless, in the horizontal distance, the difference between the transcrusal and retrolabyrinthine approaches decreased along with increased temporal lobe retraction, and almost no difference was obtained at 10 mm of retraction.
Conclusions
Posterior petrosal approaches can provide an excellent exposure of the retrochiasmatic region. Of these two approaches, namely, transcrusal and retrolabyrinthine with hearing preservation, the transcrusal approach offers greater exposure than the retrolabyrinthine approach. The beneficial effect of partial labyrinthectomy of the transcrusal approach to the retrochiasmatic region is accentuated in the exposure of the horizontal distance with less temporal lobe retraction.
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Comment
The authors studied comparatively horizontal and vertical distance and exposure area of retrochiasmatic region in transcrusal and retrolabyrinthine approaches by cadaver dissections.
Transcrusal approach enables posterior-to-anterior and downward-to-upward transtentorial access to the retrochiasmatic and retroinfundibular lesion with less temporal lobe retraction as compared to retrolabyrinthine approach. This is a new application of well-established microsurgical transpetrosal approach, which we cannot recognize as a minimally invasive one.
Drawbacks of these two posterior petrosal approaches are: hearing preservation during removal of superior and posterior semicircular canals cannot be guaranteed, lateral access to the CN III and IV and working between and around them, lateral access to PComA and AChA, time-consuming drilling, inferior bony wall of the surgical corridor, and complex anatomy of the petrosal bone.
The transphenoidal transsellar approach (with pituitary transposition) seems to be an equal or superior strategy to access retroinfundibular lesions because it enables central tumor hollowing and centripental extracapsular resection of the tumor with more symmetrical inferior visualization of CNIII and IV and perforators bilaterally and direct sight into the 3rd ventricle.
However, asymmetrical retroinfundibular tumors might be easier approached ipsilateral to the bulkier side by transcrusal approach. The detailed venographic studies, revealing anterior inflow of vein of Labbé and short inferolateral temporal bridging veins, may testify another important advantage of the transcrusal approach over the retrolabyrinthine one.
This approach is promising only in experienced neurosurgeons who are well trained in labyrintectomy or work in team with ENT surgeons. The usefulness of this keyhole posterior petrosal approach should be tested in clinical settings. Its performance can be further enchanced by endoscopy and neuronavigation.
Roman Bosnjak, M.D., Ph.D.
Ljubljana, Slovenia
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Kinoshita, M., Nakada, M., Tanaka, S. et al. Transcrusal approach to the retrochiasmatic region with special reference to temporal lobe retraction: an anatomical study. Acta Neurochir 153, 659–665 (2011). https://doi.org/10.1007/s00701-010-0899-8
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DOI: https://doi.org/10.1007/s00701-010-0899-8