De Bonis, Alessandro

OBJECTIVE Lesions of the cerebellopontine angle (CPA) and petroclival region represent a challenging surgical target due to the complex anatomy of the involved neurovascular structures. In this scenario, cranial nerve (CN) VI is particularly exposed to potential injuries due to its deep-seated location and absence of a bony foramen that serves as a reference of its most distal cisternal point, especially when it is encased or displaced by large lesions. This study aimed to provide reliable operative guidance for preventing injuries to CN VI during the retrosigmoid approach to address CPA and petrotentorial lesions. METHODS Four formalin-fixed, latex-injected anatomical specimens were dissected to highlight and investigate the relevant anatomy of the CPA and petroclival region during the retrosigmoid approach. Additionally, 50 sides of noninjected formalin-fixed specimens were dissected for morphometric evaluation. Correlations between the petrotentorial junction (PTJ), porus acusticus (PA), and trigeminal impression (TI) with the entry point of CN VI into Dorello’s canal were evaluated. An illustrative clinical case and a 3D anatomical model generated through the photogrammetry scanning technique were described. RESULTS In the sagittal plane, CN VI entrance into Dorello’s canal was found in a trajectory parallel to the PTJ, passing through the inferior aspect of the PA and 21.5 ± 1.3 mm anteriorly. In the coronal plane, the entry point of CN VI into Dorello’s canal was estimated at 6.2 ± 1.2 mm from the anterior edge of the TI in a trajectory perpendicular to the PTJ in 47 (81%) specimens. CONCLUSIONS The obtained results demonstrated two surgical strategies to locate Dorello’s canal within the retrosigmoid route: 1) approximately 20 mm anterior along the inferior edge of the PA parallel to the PTJ; and 2) approximately 6 mm inferior to the anterior edge of the TI, perpendicular to the PTJ. The defined operative strategies provide reliable anatomical guidance to locate the entrance of CN VI into Dorello’s canal within the retrosigmoid route, potentially reducing the risk of abducens nerve palsy and improving patient outcomes.

BACKGROUND AND OBJECTIVES: The lateral transorbital approach (LTOA) has gained increased recognition, but there is still a paucity of data on its effectiveness and advantages compared with the LTOA with lateral orbitotomy, herein denoted as the lateral orbital wall approach (LOWA). The aim of this study was to provide an anatomical reappraisal and the authors' clinical experience to compare the 2 approaches to the orbit and middle cranial fossa (MCF). METHODS: Eight latex-injected cadaveric specimens were used to perform LTOA and LOWA. The operative depth of each approach to key anatomical landmarks was measured. Fifty high-resolution computed tomography studies were reviewed to calculate the operative angles. We reviewed 40 consecutive cases treated with LTOA and LOWA at our institution. RESULTS: Compared with the LTOA, the LOWA provided shorter operative depths to the optic foramen ( P < .05), foramen ovale ( P < .05), and to the junction eyeball-cranial nerve II ( P = .13). It also offered better access to the anterior aspect of the orbit with less orbital content retraction. The LTOA and LOWA provided different operative angles to key anatomical landmarks in the orbit and MCF ( P < .05). In our chart review, 31 patients underwent the LTOA, whereas 9 underwent the LOWA to treat orbital and MCF lesions. Patients undergoing LOWA experienced postoperative complications related to periorbital nerves, such as frontalis palsy (n = 1) and supraorbital neuralgia (n = 1). Patients undergoing LTOA were more prone to complications associated with intraorbital manipulation (n = 4), including diplopia and ptosis. CONCLUSION: Our data suggest that the LTOA can be an effective surgical strategy for addressing orbital apex and MCF lesions. Although the LOWA provides access to the aforementioned areas, it may be more suitable for anterior orbital lesions that require direct access with wider entry exposure and extensive orbital content manipulation.

BACKGROUND AND OBJECTIVES: The intraosseous subarcuate loop (SL) is a unique variant of the anterior inferior cerebellar artery (AICA), where a loop of the artery is trapped in the petrous bone's subarcuate fossa (SF). Recognizing this variant is crucial for planning cerebellopontine angle (CPA) surgeries; however, data regarding its frequency and management vary in the published literature. A cohort from a single center was studied using MRI to assess its prevalence, and the findings were compared with the existing literature. In addition, an intraoperative guide for mobilizing the intraosseous AICA's SL was provided through a detailed step-by-step cadaveric dissection. METHODS: Two hundred fifty-eight patients who had undergone MRI scans of the CPA (516 sides) were retrospectively reviewed. MRIs displaying vascular loops visible in the axial view were analyzed using multiplanar reconstruction, and the intraosseous loop frequency was evaluated. A scoping review was undertaken to provide an overview of previously published data on its prevalence. One embalmed and latex-injected specimen with intraosseous AICA's SL was dissected through a retrosigmoid approach, and 1 surgical case was detailed, describing the procedure to release it. RESULTS: Intraosseous AICA's SL mobilization involves the identification of its entry and exit points within the petrous bone, dural incision to expose the SF, SF drilling, subarcuate artery division, and detaching the vascular loop. Preservation of a dural cuff is crucial to prevent vascular injury. We analyzed 258 brain MRIs (mean age 55 years, 42% male). The intraosseous AICA's SL was present in 4 of 516 evaluated CPAs (0.8%). The prevalence of the vascular anomaly in the reviewed literature using different radiological modalities ranged from 0.2% to 1.6%. CONCLUSION: The intraosseous AICA's SL is an uncommon anatomic variation detectable by MRI, posing an added risk in CPA surgery. Identifying and properly mobilizing it is crucial for safe vascular preservation.

Abstract We investigated the extent of access to Meckel's cave (MC) and the middle cranial fossa (MCF) protecting the internal carotid artery (ICA) using the retrosigmoid approach with endoscopic-assisted reverse anterior petrosectomy (EA-RAP). Five specimens were dissected using the limited and extended EA-RAP. Based on the bone removal of the internal acoustic meatus (IAM) and subarcuate fossa, exposure of the MC and ICA were statistically compared. The limited and extended EA-RAP allowed access to the medial and anterior MC (4 mm posterior to the first genu of the cavernous ICA, and 20 mm posterior to foramen rotundum [FR]). The access to the lateral MC varied with distance of 12 and 8 mm medial to the foramen ovale for the limited and extended EA-RAP, respectively. In the extended EA-RAP, the exposure of the ICA was gained by drilling with the 0-degree endoscope (3 mm) versus 45-degree endoscope (9 mm). The working distances from the midpoint of the IAM to the most medial point of the exposed ICA was 24 mm. The most lateral point of the exposed ICA varied between 0- and 45-degree endoscopes with a distance of 21 and 13 mm, respectively. A coronal plane from the posterior genu of the cavernous ICA and a sagittal plane to the common crus of the semicircular canals can define the area of MCF accessed by the EA-RAP. Drilling of the temporal bone should be carefully customized according to the patient and can be aided by endoscopic assistance for direct visualization to minimize the risk of injuries to ICA.

OBJECTIVE Advances in surgical technology and microneurosurgery have led to increased utilization of so-called minimally invasive approaches, including the supraorbital eyebrow (SE) and minipterional (MPT) approaches for lesions involving the interpeduncular region. This study aimed to describe and compare anatomical landmarks, along with highlighting the advantages and disadvantages of the SE and MPT approaches to the interpeduncular region. METHODS Ten formalin-fixed, latex-injected cadaveric specimens were used to perform bilateral SE and MPT approaches to the interpeduncular region. The operative depth of each approach to key anatomical landmarks was measured. Forty-five axial thin-slice computed tomography studies were reviewed to calculate the operative angles, with consideration of the midline as a reference. A 3D interactive anatomical model generated through the photogrammetry scanning technique was described. RESULTS The depths of the operative corridors of the SE and MPT approaches to the interpeduncular fossa were 83.4 ± 1.8 mm and 67.7 ± 3.2 mm, respectively (p < 0.001). The mean angle of the MPT approach to the interpeduncular fossa was significantly wider than the one provided by the SE approach (39.9° ± 5.1° vs 28.4° ± 3.6°, p < 0.001). The interpeduncular region can consistently be accessed through the carotid-oculomotor triangle with the SE approach, as well as with the MPT approach. Furthermore, the SE route offered adequate access to the interpeduncular fossa through the opticocarotid triangle. The MPT route provided direct access to the upper prepontine cistern and anterior mesencephalic zone (AMZ). CONCLUSIONS The MPT approach provides a wider and shorter operative corridor and can be employed for lesions in the interpeduncular region with extension to the prepontine cistern and ventrolateral midbrain lesions requiring access through the AMZ. The SE approach is better suited for ventromedial midbrain lesions requiring access via the interpeduncular fossa safe entry zone. Additional studies analyzing these approaches in a clinical setting will help to delineate their reliability and efficacy.

BACKGROUND AND OBJECTIVES: Access to the amygdala and hippocampus (A/H) is complex. To address the limitations and invasiveness of traditional approaches, including the Transsylvian, Subtemporal, and Supracerebellar infratentorial approaches, we developed the suprapetrous infratemporal (SPIT) approach. This study describes the nuances of this approach in both cadaveric studies and clinical cases. METHODS: Three unilateral exposures were performed using microscopic and endoscopic methodologies in the SPIT approach. After cadaveric investigation, this approach was successfully implemented in representative clinical cases. RESULTS: The SPIT approach enabled direct access to the inferior A/H, circumventing the requirement for temporal lobe retraction and detachment of the temporal lobe from the dura through a subtemporal route by drilling the upper part of the mastoid, consequently mitigating tension on the vein of Labbé. This enabled a bottom-up view because one would gain with a zygomatic osteotomy and forward projection like a mini-posterior petrosal view by using a transmastoid view, without cutting down the zygomatic arch and opening the dura subtemporally, limiting patient pain and preventing case comorbidity. The SPIT approach was performed in 2 cases of mesial temporal cavernoma presenting with seizures. The lesion was visualized intraoperatively and was successfully removed in these cases. The postoperative course was excellent with no complications, and gross total resection was radiographically confirmed with Engel Class 1a seizure freedom. CONCLUSION: The SPIT approach is a complementary approach for inferior A/H disease, combining the combined middle fossa approach modified for intradural pathology. Limited drilling of the upper aspect of the mastoid with a medial dural opening at the level of the arcuate eminence provides a direct trajectory with minimal brain retraction. Additional research encompassing a larger patient cohort and extended follow-up periods is required to substantiate the advantages of SPIT in the management of inferior A/H lesions.

BACKGROUND AND OBJECTIVES: The coexistence of complete carotico-clinoid bridge (CCB), an ossification between the anterior (ACP) and the middle clinoid (MCP), and an interclinoidal osseous bridge (ICB), between the ACP and the posterior clinoid (PCP), represents an uncommonly reported anatomic variant. If not adequately recognized, osseous bridges may complicate open or endoscopic surgery, along with the pneumatization of the ACP, especially when performing anterior or middle clinoidectomies. METHODS: According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines, a systematic scoping review was conducted up to June 5, 2023. PubMed, Scopus, Web of Science databases, and additional citations were searched. Two hundred high-resolution noncontrast computed tomography (CT) scans (400 sides) and 41 dry skulls (82 sides) were analyzed to identify the different morphology of sellar bridges, focusing on the coexistence of complete CCF and ICB. Two embalmed latex-injected heads with coexisting CCF and ICB were dissected step-by-step to show the anatomic relationship with the surrounding structures from an endoscopic and microscopic perspective. RESULTS: A total of 19 articles were included. The review identified a complete CCF and ICB rate ranging from 4.92% to 6.3%. The analysis of 200 CT scans revealed a rate of coexistence in 4% of the cases, all encountered in White women. Two different types of interclinoid bridges were identified based on the degree of bone mineralization. Both endoscopic and macroscopic step-by-step dissections highlighted variability in morphology and consistency of the sellar bridges and the close relationship with the cavernous sinus neurovascular structures. CONCLUSION: The coexistence of CCF and ICB is an anatomic variation found in 4% of cases. Preoperative knowledge of the degree of mineralization and its relationship with surrounding structures is essential to performing safe surgery and minimizing cranial nerve and vascular injuries. Preoperative high-resolution CT scans can adequately identify these anatomic variations.