Middle Cranial Fossa Approach: Anatomical Study on Skull Base Triangles as a Landmark for a Safe Anterior Petrosectomy
23. Februar 2019
28. Juli 2019
12. September 2019 (online)
Objective The Kawase approach provides access to the petroclival and posterior cavernous sinus regions, cerebellopontine angle, and upper basilar artery territory. Nevertheless, it remains one of the most challenging approach for neurosurgeons, due to the considerable related morbidity and mortality. The goal of this study was to evaluate the relationship between anatomical landmarks and their possible variations, and to measure the extension of the Kawase space, to define the reliability of these landmarks while performing an anterior petrosectomy.
Design Using eight cadaveric specimens (15 sides), an anatomical dissections and extradural exposure of the Kawase area were performed.
Settings A two-step analysis of the distances between the mandibular branch of the trigeminal nerve (V3) and the structures at risk of iatrogenic damage was performed.
Main outcome measures We measured the distance between V3 and the basal turn of the cochlea, and between V3 and the internal acoustic canal (IAC), analyzing the limits of bone resection without causing hearing damage.
Results We analyzed eight cadaveric (15 sides) formalin-fixed heads injected with colored silicone: four males and four females of Caucasian race (mean age: 73.83 years). We found a mean distance of 10.46 ± 1.13 mm between the great superficial petrous nerve (GSPN) intersection with V3 and the basal turn of the cochlea, and of 11.92 ± 1.71 mm between the origin point of V3 from the Gasserian ganglion and the fundus of the IAC.
Conclusion The knowledge of the safe distance between the most applicable anatomic landmarks and the hearing structures is a practical and useful method to perform this approach reducing related comorbidity.
- 1 Adams Pérez J, Rassier Isolan G, Pires de Aguiar PH, Antunes AM. Volumetry and analysis of anatomical variants of the anterior portion of the petrous apex outlined by the Kawase triangle using computed tomography. J Neurol Surg B Skull Base 2014; 75 (03) 147-151
- 2 Arìstegui M, Cokkeser Y, Saleh E. , et al. Surgical anatomy of the extended middle cranial fossa approach. Skull Base Surg 1994; 4 (04) 181-188
- 3 Roche P-H, Lubrano V, Noudel R, Melot A, Régis J. Decision making for the surgical approach of posterior petrous bone meningiomas. Neurosurg Focus 2011; 30 (05) E14
- 4 Rigante L, Herlan S, Tatagiba MS, Stanojevic M, Hirt B, Ebner FH. Petrosectomy and topographical anatomy in traditional Kawase and posterior intradural petrous apicectomy (PIPA) approach: an anatomical study. World Neurosurg 2016; 86: 93-102
- 5 Tripathi M, Deo RC, Suri A. , et al. Quantitative analysis of the Kawase versus the modified Dolenc-Kawase approach for middle cranial fossa lesions with variable anteroposterior extension. J Neurosurg 2015; 123 (01) 14-22
- 6 Shibao S, Borghei-Razavi H, Orii M, Yoshida K. Anterior transpetrosal approach combined with partial posterior petrosectomy for petroclival meningiomas with posterior extension. World Neurosurg 2015; 84 (02) 574-579
- 7 Van Gompel JJ, Alikhani P, Youssef AS, Loveren HR, Boyev KP, Agazzi S. Anterior petrosectomy: consecutive series of 46 patients with attention to approach-related complications. J Neurol Surg B Skull Base 2015; 76 (05) 379-384
- 8 Altieri R, Sameshima T, Pacca P. , et al. Detailed anatomy knowledge: first step to approach petroclival meningiomas through the petrous apex. Anatomy lab experience and surgical series. Neurosurg Rev 2017; 40 (02) 231-239
- 9 Maina R, Ducati A, Lanzino G. The middle cranial fossa: morphometric study and surgical considerations. Skull Base 2007; 17 (06) 395-403
- 10 Guo X, Tabani H, Griswold D. , et al. Hearing preservation during anterior petrosectomy: the “Cochlear Safety Line”. World Neurosurg 2017; 99: 618-622
- 11 Kawase T, Shiobara R, Toya S. Middle fossa transpetrosal-transtentorial approaches for petroclival meningiomas. Selective pyramid resection and radicality. Acta Neurochir (Wien) 1994; 129 (3-4): 113-120
- 12 Hsu FP, Anderson GJ, Dogan A. , et al. Extended middle fossa approach: quantitative analysis of petroclival exposure and surgical freedom as a function of successive temporal bone removal by using frameless stereotaxy. J Neurosurg 2004; 100 (04) 695-699
- 13 Gross BA, Dunn IF, Du R, Al-Mefty O. Petrosal approaches to brainstem cavernous malformations. Neurosurg Focus 2012; 33 (02) E10
- 14 Wang J, Yoshioka F, Joo W, Komune N. A-The cochlea in skull base surgery_ an anatomy study. 2016 :1–11. doi: 10.3171/2015.8.JNS151325
- 15 Ahmed O, Walther J, Theriot K, Manuel M, Guthikonda B. Morphometric analysis of bone resection in anterior petrosectomies. J Neurol Surg B Skull Base 2016; 77 (03) 238-242
- 16 Tubbs RS, Menendez J, Loukas M. , et al. The petrosal nerves: anatomy, pathology, and surgical considerations. Clin Anat 2009; 22 (05) 537-544
- 17 Pensak ML, Kerr RG, Leung R, Keller JT. The enigmatic trigeminal caroticodural fold: an anatomic description and surgical relevance to anterior petrosectomy. Laryngoscope 2009; 119 (06) 1060-1066
- 18 Borghei-Razavi H, Tomio R, Fereshtehnejad SM. , et al. Anterior petrosal approach: the safety of Kawase triangle as an anatomical landmark for anterior petrosectomy in petroclival meningiomas. Clin Neurol Neurosurg 2015; 139: 282-287
- 19 Watanabe A, Nagaseki Y, Ohkubo S. , et al. Anatomical variations of the ten triangles around the cavernous sinus. Clin Anat 2003; 16 (01) 9-14
- 20 Xu Z, Wang W, Zhang J, Liu W. Front Matter: Volume 10461. AOPC 2017 Opt Spectrosc Imaging 2017 ;25(6):0. doi:10.1097/SCS.0000000000001073
- 21 Miller CG, van Loveren HR, Keller JT, Pensak M, el-Kalliny M, Tew Jr JM. Transpetrosal approach: surgical anatomy and technique. Neurosurgery 1993; 33 (03) 461-469 , discussion 469
- 22 Diaz Day J. The middle fossa approach and extended middle fossa approach: technique and operative nuances. Neurosurgery 2012; 70 (2, Suppl Operative): 192-201
- 23 Kim SM, Lee HY, Kim HK, Zabramski JM. Cochlear line: a novel landmark for hearing preservation using the anterior petrosal approach. J Neurosurg 2015; 123 (01) 9-13