Combined approaches of skull base 360°

1. Combined approaches of
skull base 360°
26-6-2016
6.55 pm

2. Great teachers – All this is their work .
I am just the reader of their books .
Prof. Paolo castelnuovo
Prof. Aldo Stamm Prof. Mario Sanna
Prof. Magnan

3. For Other powerpoint presentatioins
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“ Skull base 360° ”
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getting more & more information
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4. Anterior skull base is combined with Lateral skull
base [ neurosurgical skull base or trans-temporal
skull base approaches ]

5. Anterior skull base & Neurosurgical skull base can be combined like in this ossifying
fibroma video https://www.youtube.com/watch?v=3nr5f8Wbsk4 . See the microscope
used by neurosurgeon & endoscope by the ENT surgeon in the below photo at the
same time . - case done by Dr .Satish jain [ https://www.facebook.com/satish.jain.75 ]
[ http://www.jainenthospital.org/ ]

6. Case done by Dr .Satish jain
[ https://www.facebook.com/satish.jain.75 ]
[ http://www.jainenthospital.org/ ]
Another case of ossifying fibroma without
combined approach – going from nose to
pterion – click
https://www.youtube.com/watch?v=tp1vYADb5
xc

7. JNA surgery by 4 corridors approach - by Dr.
James K. Liu - I feel this 4 corridor is safest
surgery for intracavernous & intracranial
extension JNAs rather than removing only by
nose. Orbitozygomatic transcavernous gives
proximal & distal control of ICA . Endoscopic
Caldwell-Luc ( Tranasmaxillary ) preserves Nose
anatomy – see video
https://www.youtube.com/watch?v=ekwOfEmH
GWg&feature=youtu.be

8. JNA selection of approach
discussion
https://www.facebook.com/groups/3
47913135290330/permalink/575333
442548297/

9. 360-degree skull base surgery for giant pituitary adenoma.
A. Coronal T1 with contrast MRI.
B. Sagittal T1 with contrast MRI.

10. The patient is a 43-year-old female who presented
with worsening vision changes. An MRI revealed a
giant pituitary tumor with severe suprasellar extension
and clival invasion (Figs 21–6A and 21–6B). Prolactin
levels were normal. Also, multiple flow voids
are noted surrounding the tumor and “pinching”
the tumor margins. These are the anterior (ACAs)
and middle cerebral (MCAs) arteries. This case illustrates
the importance of having a knowledge and
understanding of ALL skull base surgical options.
This tumor should be examined with a 360-degree
approach.
An endonasal approach should be used for the clival and sellar portions and
could likely
even decompress the midportion of the suprasellar
portion for optic chiasm decompression. However
an anterior-lateral (orbito-zygomatic-craniotomy)
approach would be best for clearance of the tumor
away from the ACAs and MCAs and the intraventricular
portion of the tumor. Endoscopic assistance
via the craniotomy could be used in conjunction
with the microscope to get angled views.

11. Pterional & anterior skull base are combined .

12. Prof . Mario sanna says combined approaches in lateral
skull base into two
1. Retrolabyrinthine Subtemporal Transapical [
= transpetrous ] and Retrolabyrinthine
transtentorial approaches
2. Combined Transpetrous approaches + FTOZ

13. Retrolabyrinthine Subtemporal
Transapical [ = transpetrous ] and
Retrolabyrinthine transtentorial
approaches

14. 1. Retrolabyrinthine Transpetrous ( = Transapical
)Subtemporal Approach
2. Retrolabyrinthine Transpetrous ( = Transapical
)Subtemporal Transtentorial Approach
Retrolabyrinthine Subtemporal
Transapical Approach
Retrolabyrinthine Subtemporal
Transtentorial Approach

15. Retrolabyrinthine Subtemporal Transapical
(Transpetrous Apex) Approach
Schematic drawing showing the
incision to be performed.
A retrolabyrinthine approach is
performed.

16. The dura of the middle fossa is
detached from the superior surface of
the temporal bone from posterior to
anterior.
With further detachment of the
dura, the middle meningeal
(MMA) artery is clearly identified.

17. The middle meningeal artery (MMA)
and the three branches
(V1, V2, V3) of the trigeminal nerve
are identified.
View after cutting the middle
meningeal artery (MMA) and
the mandibular branch of the
trigeminal nerve (V).

18. The internal auditory canal (IAC)
is identified.
A large diamond burr is used to
drill the petrous apex.

19. The petrous apex has been
drilled. The internal carotid artery
(ICA) is identified.
At higher magnification, the
abducent nerve (VI) is identified
at the level of the tip of the petrous
apex (PA).

20. Panoramic view showing the
structures after opening of the
posterior fossa dura.
At higher magnification, the anterior
inferior cerebellar artery (AICA)is
seen stemming from the basilar
artery (BA) at the prepontine cistern.
The artery is crossed by the
abducent nerve (VI). Note the good
control of the prepontine cistern
through this approach.

21. Tilting the microscope downward,
the lower cranial nerves
are well seen.

22. Retrolabyrinthine Subtemporal
Transtentorial Approach
The retrolabyrinthine craniotomy
has been performed. The petrous
apex has been partially drilled.
The middle fossa dura (*) is
incised.

23. The tentorium (*) is cut, taking care not to injure the
trochlear nerve.
The tentorium is further cut until
the tentorial notch is
reached. With retraction of the
temporal lobe the optic (II),
oculomotor
(III) and contralateral oculomotor
(IIIc) nerves are seen.

24. Branches of the trigeminal nerve (V1, V2, V3) at the level of
the lateral wall of the cavernous sinus.

25. A view of the cerebellopontine angle
through the retrolabyrinthine
approach Note the narrow field and
limited control.
Posterior fossa dura (PFD) structures
exposed through the standard
retrolabyrinthine approach.
A view of the posterior fossa dura
through the combined
retrolabyrinthine subtemporal
transapical approach.

26. The middle fossa dura has
been cut. The oculomotor
nerve (III) is clearly seen.
With more retraction of the
temporal lobe and the tentorium
(*), the optic nerve (II) is seen.

27. Combined Transpetrous approaches
+ FTOZ
1. Transpetrous approaches – to prevent brain
retraction & get control of posterior fossa
2. FTOZ – to get control of middle cranial fossa

28. Advantages of the Combined Transpetrous + FTOZ approaches
1. Complete and single-stage removal of large tumors extending to
both the posterior and middle fossae. The FTOZ approach offers
excellent control of the middle and infratemporal fossa components
but has poor control of the posterior fossa. On the other hand, the
transpetrous approaches afford excellent exposure of the posterior
fossa with minimal middle fossa control. The combination of both
approaches provides excellent visibility of both fossae, particularly at
the area of Meckel’s cave where the tumor components usually
interconnect.
2. The extensive bone removal allows maximal exposure while
minimizing the amount of brain retraction needed.

29. Upper incision for FTOZ , lower incision
for transpetrous approaches

30. Transpetrous approaches are – for better understanding
click PPT
http://www.slideshare.net/muralichandnallamothu/petrou
s-apex-360-48222034
1. Retrolabyrinthine Transpetrous ( = Transapical ) &
2. Translabyrinthine Transpetrous ( = Transapical ) &
3. Transcochlear Transpetrous ( = Transapical )

31. Combined Transpetrous approaches
+ FTOZ
1. Retrolabyrinthine Transpetrous ( =
Transapical ) + FTOZ
2. Translabyrinthine Transpetrous ( =
Transapical ) + FTOZ &
3. Transcochlear Transpetrous ( =
Transapical ) + FTOZ
4. Infratemporal fossa approach
type B + Transzygomatic

32. Neurosurgeons are doing FTOZ + kawase approach to
get control of middle cranial fossa & posterior cranial
fossa respectively
For FTOZ + Kawase approach click
1. https://www.youtube.com/watch?v=qgItZDwRYjk
2. https://www.youtube.com/watch?v=M89uijtuzQA
3. https://www.youtube.com/watch?v=es-U3QitxdY
4. https://www.youtube.com/watch?v=vDGO4kVy0Gc
5. http://www.aiimsnets.org/skull_base_tumors.asp
6. http://aiimsnets.org/AnteriorTranspetrosalapproach.asp#
others
https://www.youtube.com/results?search_query=frontotemporal+orbitozygo
matic+approach
https://www.youtube.com/results?search_query=kawase+approach

33. FTOZ + kawase approch cadaver
albums
• https://www.facebook.com/groups/38350835
5070291/permalink/896897763731345/
• https://www.facebook.com/groups/38350835
5070291/permalink/897122833708838/

34. For Other powerpoint presentatioins
of
“ Skull base 360° ”
I will update continuosly with date tag at the end as I am
getting more & more information
click
www.skullbase360.in
- you have to login to slideshare.net with Facebook
account after clicking www.skullbase360.in