• World Neurosurg · Jun 2020

    Extended anterior petrosectomy through the transcranial middle fossa approach and extended endoscopic transphenoidal-transclival approaches: qualitative and quantitative anatomic analysis.

    • Aurel Hasanbelliu, Norberto Andaluz, Alberto Di Somma, Jeffrey T Keller, Lee A Zimmer, Ravi N Samy, Myles L Pensak, and Mario Zuccarello.
    • Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
    • World Neurosurg. 2020 Jun 1; 138: e405-e412.

    BackgroundPetroclival tumors and ventrolateral lesions of the pons present unique surgical challenges. This cadaveric study provides qualitative and quantitative anatomic comparison for an anterior petrous apicectomy through the transcranial middle fossa (TMF) and expanded endoscopic transsphenoidal-transclival approaches.MethodsIn 10 silicone-injected heads, the petrous apex and clivus were drilled extradurally using middle fossa and endonasal approaches. With in situ and frameless stereotactic navigation, we defined consistent points to compare working areas, bone removal volumes, approach angles, and surgical freedom.ResultsMean exposed TMF area (21.03 ± 3.46 cm2) achieved a 44.71 ± 4.13° working angle to the brainstem between cranial nerves V and VI. Kawase's rhomboid area measured 1.76 ± 0.34 cm2, and bone removal averaged 1.20 ± 0.12 cm3 at the petrous apex. Surgical freedom on the lateral brainstem was higher halfway between cranial nerves V and VI at the center of the rhomboid compared with midline at the basilar sulcus (P < 0.01). After clivectomy and petrous apicectomy, mean exposed expanded endoscopic transsphenoidal-transclival area was 5.29 ± 0.66 cm2. Approach from either nostril showed no statistically significant differences in surgical freedom at the foramen lacerum and midpoint basilar sulcus. At the petrous apex, bone volume removed and area exposed were significantly larger for the TMF approach (P < 0.001).ConclusionsExpanded transclival anterior petrosectomy through the TMF approach provides an adequate corridor to lesions in the upper ventrolateral pons. The expanded endoscopic transsphenoidal-transclival approach better fits midline lesions not extending laterally beyond cranial nerve VI and C3 carotid when evaluating normal anatomic parameters.Copyright © 2020 Elsevier Inc. All rights reserved.

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