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Extended endoscopic endonasal transclival approach to the ventrolateral brainstem and related cisternal spaces: anatomical study

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Abstract

Advances in endoscopic endonasal skull base surgery have led to the development of new routes to areas beyond the midline skull base. Recently, feasible surgical corridors to the lateral skull base have been described. The aim of this study was to describe the anatomical exposure of the ventrolateral brainstem and posterior fossa through an extended endoscopic endonasal transclival transpetrosal and transcondylar approach. Six human heads were used for the dissection process. The arterial and venous systems were injected with red- and blue-colored latex, respectively. A pre- and postoperative computed tomography (CT) scan was carried out on every head. The endoscopic endonasal transclival approach was extended through an anterior petrosectomy and a medial condylectomy. A three-dimensional model of the approach was reconstructed, using a dedicated software, from the overlapping of the pre- and post-dissection CT imaging of the specimen. An extended endoscopic transclival approach allows to gain access through an extradural anterior petrosectomy and medial condylectomy to the anterolateral surface of the brainstem and the posterior fossa. Two main intradural anatomical corridors can be described: first, between the V cranial nerve in the prepontine cistern and the VII–VIII cranial nerves in the cerebellopontine and cerebellomedullary cistern; second, between the VII–VIII cranial nerves and the IX cranial nerve, in the premedullary cistern. Extending the transclival endoscopic approach by performing an extradural anterior petrosectomy and a medial condylectomy provides a safe and wide exposure of the anterolateral brainstem with feasible surgical corridors around the main neurovascular structures.

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Notes

  1. M. Samii/E. Knosp, Approaches to the Clivus—Approaches to No Man’s Land (Springer-Verlag, Berlin, Heidelberg 1992)

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Acknowledgement

The present paper has been supported by the Maratò TV3 Grant Project ref. 411/U/2011.

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Authors and Affiliations

  1. Department of Neurological Science, Division of Neurosurgery, University of Padua, Via Giustinianeo 2, 00135, Padua, Italy

    Elena d’Avella

  2. Department of Neurological Science, Division of Neurosurgery, University of Messina, Messina, Italy

    Flavio Angileri

  3. Department of Neurological Sciences, Division of Neurosurgery, University of Naples Federico II, Naples, Italy

    Vita Stagno & Luigi Maria Cavallo

  4. Department of Neurosurgery, Hospital Clinic, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain

    Matteo de Notaris & Joaquin Enseñat

  5. Laboratory of Surgical NeuroAnatomy (LSNA), Human Anatomy and Embryology Unit, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain

    Alessandro Weiss & Alberto Prats-Galino

  6. Department of Radiology, Hospital Clinic, Faculty of Medicine, Universitat de Barcelona, Barcelona, Spain

    Joan Berenguer Gonzales

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  1. Elena d’Avella
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Correspondence to Elena d’Avella.

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Comments

Amir R. Dehdashti, New York, USA

The authors describe a nice anatomical illustration of the so called "far medial approach." The anatomical study has already been performed before, but there is definitely room for more exploration of this rather unusual surgical approach. The practice of this approach in real life is tedious and significantly longer than a far lateral approach. The microsurgical dexterity to preserve the function of CN V–XII are reduced compared to open traditional skull base approaches. While we should welcome the introduction of new endoscopic skull base corridors, one should carefully assess the real advantage of this endoscopic exposure versus the far lateral approach. The exposure time, higher risk of CSF leak, and non-visualization of cranial nerves in intradural pathologies and oblique surgical angle are significant disadvantages of this approach. I do however favor this approach for purely extradural lesions of petrous apex and anteromedial petroclival lesions. Learning curve will prove us if we will use this approach more often for intradural tumors in the future.

Engelbert Knosp, Vienna, Austria

To reach the central skull base and the ventral brainstem was challenging over the decadesFootnote 1 of skull base surgery. With the development of endoscopic surgery, this field has been changed radically.

The large-scale approaches became less traumatic and new techniques allow for reaching areas unattainable with microscopic techniques. Detailed anatomical knowledge is a prerequisite for these new surgical techniques.

This publication is an excellent example of anatomy applied to surgical needs, with brilliant pictures and clear descriptions. The surgical case demonstrates the high standard which is the driving force for this anatomical work. But anatomy itself changed significantly. New technologies have entered into anatomy, e.g., neuronavigation of 3D reconstruction and endoscopic surgery, and became part of modern anatomy. One strong part of this publication is that the authors use all these technologies not only during surgery, but also in the anatomical Lab. All anterior approaches to the skull base have, in common, their limitation towards lateral. This is especially true at the clival area, with the narrowest window to the brainstem limited by the abducens nerves, the internal carotid artery, and the hypoglossal nerves.

Although it is possible to remove bone at the petrous apex to reach even the horizontal petrous ICA, it is very risky to displace the ICA in a sufficient way. Three millimeters as mentioned above seems for me theoretical and maybe not worth for these risks. If the tumor—e.g., a chordoma—reaches the petrous apex and the internal carotid artery in its petrous portion, one is able to reach these limits.

In contrast to the aggressive dissection towards lateral, the authors were much more conservative to enlarge this approach superiorly towards the dorsum sellae or towards the cranio-cervical region.

Although I disagree with the concept to displace the pituitary in some cases, it is necessary to reach the dorsum sellae and the upper part of the pons.

Henry W. S. Schroeder, Greifswald, Germany

The authors present an anatomical study describing an extended endoscopic endonasal transclival approach to the ventrolateral brainstem. The transclival approach was enlarged by partial resection of the anterior petrous apex and the medial condyle which provided extra space to explore the lateral brainstem.

The expanded endoscopic endonasal approach has been well established for the resection of skull base tumors in the last decade. It provides several advantages compared with the transcranial approach. Especially, when the tumor is located medially to the cranial nerves, the endonasal approach is beneficial. Using the endoscope, the surgeon brings the eye close to the surgical target with perfect magnification and illumination even in a very deep surgical field. Endoscopes with angled optics enable a look around a corner or behind neurovascular structures which allows the removal of lateral tumor extensions. In my experience, using angulated endoscopes and curved instruments, extensive drilling of the petrous apex can frequently be avoided.

Although I agree that the endonasal approach is the preferred approach for extradural midline skull base lesions, chordomas, most chondrosarcomas, pituitary tumors, and suprasellar craniopharyngeomas, I still use transcranial approaches in most of my skull base tumor surgeries. As the authors describe, there is significant traumatization of the nasal cavity with bilateral middle turbinectomy, posterior septectomy, anterior sphenoidotomy, antrostomy of the maxillary sinus, and dissection of the pterygopalatine fossa when performing this extended endonasal approach. Reconstruction of the skull base is complex. Furthermore, the postoperative discomfort for the patient with crusting and discharge as well as the need for nasal care is prolonged. Therefore, the pros and cons of the approaches should be balanced and the best one should be selected for each individual patient.

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d’Avella, E., Angileri, F., de Notaris, M. et al. Extended endoscopic endonasal transclival approach to the ventrolateral brainstem and related cisternal spaces: anatomical study. Neurosurg Rev 37, 253–260 (2014). https://doi.org/10.1007/s10143-014-0526-x

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