Anteromedial Petrous (Gardner's) Triangle: Surgical Anatomy and Relevance for Endoscopic Endonasal Approach to the Petrous Apex and Petroclival Region.
Journal
Operative neurosurgery (Hagerstown, Md.)
ISSN: 2332-4260
Titre abrégé: Oper Neurosurg (Hagerstown)
Pays: United States
ID NLM: 101635417
Informations de publication
Date de publication:
19 Oct 2023
19 Oct 2023
Historique:
received:
25
02
2023
accepted:
13
08
2023
medline:
19
10
2023
pubmed:
19
10
2023
entrez:
19
10
2023
Statut:
aheadofprint
Résumé
Triangular corridors have been used as reliable surgical entry points for open transcranial approaches to the petrous apex (PA) and petroclival region (PCR). The endoscopic endonasal approaches have grown rapidly in the last decade, and the indications have advanced. The knowledge of accurate and reliable anatomic landmarks through endoscopic endonasal route is essential and remain to be established. The purpose of this study was to describe the feasibility and surgical exposure of the anteromedial petrous (Gardner's) triangle as a novel corridor to the PA and PCR. Five anatomic specimens were dissected. The PA and PCR were accessed through endoscopic endonasal approaches and contralateral transmaxillary approach. The limits of the anteromedial petrous (Gardner's) triangle were identified and dissected and associated measurements performed. The dissection was divided into 6 steps. The limits of the anteromedial petrous (Gardner's) triangle were identified and defined by the paraclival internal carotid artery anterolaterally, the abducens nerve posteromedially, and the petroclival synchondrosis inferiorly. Three lines were established following the limits of the triangle. The mean distance of the anterolateral limit was 10.03 mm (SD = 0.94), of the posteromedial limit was 20.06 mm (SD = 2.90), and of the inferior limit was 17.99 mm (SD = 2.99). The mean area was 87.56 mm2 (SD = 20.06). The 3 anatomic landmarks with a critical role to safely define the triangle were the pterygosphenoidal fissure, the petrosal process of the sphenoid bone, and the petroclival synchondrosis. The anteromedial (Gardner's) triangle is a well-defined bone corridor which provides access to the entire petrous bone and petroclival junction through endoscopic endonasal route. Regardless of the anatomic variations or tumor location, the landmarks of the abducens nerve, paraclival internal carotid artery, and petroclival synchondrosis are key for understanding lateral access to tumors extending from the clivus.
Sections du résumé
BACKGROUND AND OBJECTIVES
OBJECTIVE
Triangular corridors have been used as reliable surgical entry points for open transcranial approaches to the petrous apex (PA) and petroclival region (PCR). The endoscopic endonasal approaches have grown rapidly in the last decade, and the indications have advanced. The knowledge of accurate and reliable anatomic landmarks through endoscopic endonasal route is essential and remain to be established. The purpose of this study was to describe the feasibility and surgical exposure of the anteromedial petrous (Gardner's) triangle as a novel corridor to the PA and PCR.
METHODS
METHODS
Five anatomic specimens were dissected. The PA and PCR were accessed through endoscopic endonasal approaches and contralateral transmaxillary approach. The limits of the anteromedial petrous (Gardner's) triangle were identified and dissected and associated measurements performed.
RESULTS
RESULTS
The dissection was divided into 6 steps. The limits of the anteromedial petrous (Gardner's) triangle were identified and defined by the paraclival internal carotid artery anterolaterally, the abducens nerve posteromedially, and the petroclival synchondrosis inferiorly. Three lines were established following the limits of the triangle. The mean distance of the anterolateral limit was 10.03 mm (SD = 0.94), of the posteromedial limit was 20.06 mm (SD = 2.90), and of the inferior limit was 17.99 mm (SD = 2.99). The mean area was 87.56 mm2 (SD = 20.06). The 3 anatomic landmarks with a critical role to safely define the triangle were the pterygosphenoidal fissure, the petrosal process of the sphenoid bone, and the petroclival synchondrosis.
CONCLUSION
CONCLUSIONS
The anteromedial (Gardner's) triangle is a well-defined bone corridor which provides access to the entire petrous bone and petroclival junction through endoscopic endonasal route. Regardless of the anatomic variations or tumor location, the landmarks of the abducens nerve, paraclival internal carotid artery, and petroclival synchondrosis are key for understanding lateral access to tumors extending from the clivus.
Identifiants
pubmed: 37856762
doi: 10.1227/ons.0000000000000959
pii: 01787389-990000000-00934
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
Copyright © Congress of Neurological Surgeons 2023. All rights reserved.
Références
Fournier HD, Mercier P, Roche PH. Surgical anatomy of the petrous apex and petroclival region. Adv Tech Stand Neurosurg. 2007;32:91-146.
Kawase T, Toya S, Shiobara R, Mine T. Transpetrosal approach for aneurysms of the lower basilar artery. J Neurosurg. 1985;63(6):857-861.
Kawase T, Shiobara R, Toya S. Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients. Neurosurgery. 1991;28(6):869-875; discussion 875-6.
Muto J, Prevedello DM, Ditzel Filho LF, et al. Comparative analysis of the anterior transpetrosal approach with the endoscopic endonasal approach to the petroclival region. J Neurosurg. 2016;125(5):1171-1186.
Hitselberger WE, Pulec JL. Trigeminal nerve (posterior root) retrolabyrinthine selective section. Operative procedure for intractable pain. Arch Otolaryngol. 1972;96(5):412-415.
Russell SM, Roland JT Jr, Golfinos JG. Retrolabyrinthine craniectomy: the unsung hero of skull base surgery. Skull Base. 2004;14(1):63-71; discussion 71.
Samii M, Tatagiba M, Carvalho GA. Retrosigmoid intradural suprameatal approach to Meckel's cave and the middle fossa: surgical technique and outcome. J Neurosurg. 2000;92(2):235-241.
Patel CR, Wang EW, Fernandez-Miranda JC, Gardner PA, Snyderman CH. Contralateral transmaxillary corridor: an augmented endoscopic approach to the petrous apex. J Neurosurg. 2018;129(1):211-219.
Eytan DF, Kshettry VR, Sindwani R, Woodard TD, Recinos PF. Surgical outcomes after endoscopic management of cholesterol granulomas of the petrous apex: a systematic review. Neurosurg Focus. 2014;37(4):e14.
Ditzel Filho LF, Prevedello DM, Dolci RL, et al. The endoscopic endonasal approach for removal of petroclival chondrosarcomas [published correction appears in Neurosurg Clin N Am. 2015 Oct;26(4):xi. Kassam, Amin [added]]. Neurosurg Clin N Am. 2015;26(3):453-462.
Zoli M, Milanese L, Bonfatti R, et al. Clival chordomas: considerations after 16 years of endoscopic endonasal surgery. J Neurosurg. 2018;128(2):329-338.
Mehta GU, DeMonte F, Su SY, Kupferman ME, Hanna EY, Raza SM. Endoscopic endonasal transpterygoid transnasopharyngeal management of petroclival chondrosarcomas without medial extension. J Neurosurg. 2018;131(1):184-191.
Mangussi-Gomes J, Alves-Belo JT, Truong HQ, et al. Anatomical limits of the endoscopic contralateral transmaxillary approach to the petrous apex and petroclival region. J Neurol Surg B Skull Base. 2022;83(1):44-52.
Wang WH, Lieber S, Mathias RN, et al. The foramen lacerum: surgical anatomy and relevance for endoscopic endonasal approaches. J Neurosurg. 2019;131(5):1571-1582.
Gray H. Anatomy of the Human Body, 20th ed. Lea & Febiger; 1918.
Champagne PO, Zenonos GA, Wang EW, Snyderman CH, Gardner PA. The rhinopharyngeal flap for reconstruction of lower clival and craniovertebral junction defects. J Neurosurg. 2021;135(5):1319-1327.
Macewen W. Pyogenic infective diseases of the brain and spinal Cord: meningitis, Abscess of brain, infective sinus thrombosis. Glasgow Med J. 1894;41(1):57-63.
Parkinson D. A surgical approach to the cavernous portion of the carotid artery. Anatomical studies and case report. J Neurosurg. 1965;23(5):474-483.
Mullan S. Treatment of carotid-cavernous fistulas by cavernous sinus occlusion. J Neurosurg. 1979;50(2):131-144.
Glassock ME 3rd, Jackson CG, Dickins JR, Wiet RJ. Panel discussion: glomus jugulare tumors of the temporal bone. The surgical management of glomus tumors. Laryngoscope 1979;89(10 Pt 1):1640-1654.
Hakuba A, Tanaka K, Suzuki T, Nishimura S. A combined orbitozygomatic infratemporal epidural and subdural approach for lesions involving the entire cavernous sinus. J Neurosurg. 1989;71(5 Pt 1):699-704.
Dolenc VV. General approach to the cavernous sinus. In: Anatomy and surgery of the cavernous sinus. Springer Vienna; 1989:139-169.
Hendricks BK, Benet A, Lawrence PM, Benner D, Preul MC, Lawton MT. Anatomical triangles for use in skull base surgery: a comprehensive review. World Neurosurg. 2022;164:79-92.
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(4):695-699.
Isolan GR, Krayenbühl N, de Oliveira E, Al-Mefty O. Microsurgical anatomy of the cavernous sinus: measurements of the triangles in and around it. Skull Base. 2007;17(6):357-367.
Maina R, Ducati A, Lanzino G. The middle cranial fossa: morphometric study and surgical considerations. Skull Base. 2007;17(6):395-403.
Watanabe A, Nagaseki Y, Ohkubo S, et al. Anatomical variations of the ten triangles around the cavernous sinus. Clin Anat. 2003;16(1):9-14.