Staged “Intentional” Bridging Vein Ligation: A Safe Strategy in Gaining Wide Access to Skull Base Tumors

Background: The venous drainage of the temporal lobe, through bridging veins to the middle cranial fossa, is pivotal in determining the surgical corridor for skull base lesions. We hypothesized that staged “intentional” ligation of the dominant pathway of venous drainage would provide a safer and wider access to skull base tumors. We study the indications and safety of this surgical strategy in the management of skull base lesions. Cases: Out of the 280 patients of skull base tumors treated by the orbito-zygmatic or transpetrosal approaches, from 1998 to 2013, eight patients underwent planned ligation of the bridging veins from the temporal lobe to the middle cranial fossa floor in the first stage, followed by definitive surgery through the desired skull base approach, in the second stage. Results: The diagnoses were recurrent craniopharyngioma in four, and meningioma in four cases. Venograms done after the first stage procedure, showed obliteration of the dominant venous drainage with opening up of anastomotic venous channels, in all patients. All patients tolerated first-stage procedure well; only one patient showed asymptomatic mild temporal lobe edema on MRI, which resolved in 3 weeks. None of the patients had venous complications after definitive surgery. Conclusion: The surgical strategy may allow skull base surgeons better surgical corridor and safety of venous structures during the definitive surgery.