Advanced Neuroimaging and Preoperative Planning for Complex Skull Base Surgery

Introduction: There have been significant advances in neuroimaging both in terms of native image resolution and in post-processing techniques. We describe a case that illustrates how additional preoperative neuroimaging altered the choice of surgical approach and facilitated resection of a complex skull base meningioma with brainstem compression in a 49-year-old patient.

Method: In addition to standard neuroimaging, we obtained a 3D CT angiogram to assess the relationship of the tumor to the vasculature. Source images were reconstructed to generate multiplanar 3D volume-rendered views of the meningioma and the skull base. The 3D volume rendering of the CT angiogram dataset preoperatively allowed us to plan a safe and accurate approach to the tumor via a modified retrosigmoid suboccipital route as opposed to a more extensive far-lateral approach to the skull base. Preoperative modeling of the intracranial anatomy correlated well with the intraoperative anatomy, allowing us to resect the tumor with good patient outcome.

Conclusion: Advances in neuroimaging and imaging analysis software should be exploited to plan safer surgical corridors to skull base pathology and anticipate for critical anatomy preoperatively. Future developments will allow integration of multimodality imaging datasets with greater anatomical detail. The 3D volume-rendered CT angiography provides real-time visualization that closely matches the individual anatomy of the patient and offers the possibility of visualizing vascular structures and surface landmarks with high resolution. In the retrosigmoid approach, the advantage of preoperative visualization provides additional precision and safety for the patient by accurate localization of the transverse sigmoid sinus complex. Preoperative appreciation of the imaging anatomy is critical to effecting a successful surgery and complication avoidance.