The Suprameatal Dural Flap for Superior Petrosal Vein Protection during the Retrosigmoid Intradural Suprameatal Approach

Abstract

Object The drilling of the suprameatal bone during the retrosigmoid intradural suprameatal approach (RISA) puts the superior petrosal vein complex at risk of heating and mechanical injury, which may lead to cerebellar swelling and infarction. We present a new technique to protect the superior petrosal venous complex during suprameatal bone drilling.

Material and methods A microanatomical laboratory investigation on cadaver was conducted. The surgical technique is described and intraoperative schematic pictures are provided.

Results The surgical steps of this technique and the related intraoperative images are reported. One case illustration regarding the removal of a large petrous apex meningioma with Meckel cave extension is described to demonstrate the application of the technique in a clinical setting.

Conclusions Reflecting a dural flap onto the posterior trigeminal nerve root and the superior petrosal vein complex can be a simple way to protect the nerve and the vein during the suprameatal bone drilling during the RISA.

Keywords

retrosigmoid intradural suprameatal approach - petrosal vein - trigeminal nerve - cerebellopontine angle - Meckel cave

• References

• 1 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
• 2 Koerbel A, Gharabaghi A, Safavi-Abbasi S , et al. Venous complications following petrosal vein sectioning in surgery of petrous apex meningiomas. Eur J Surg Oncol 2009; 35 (7) 773-779
• 3 Rhoton Jr AL. The posterior fossa veins. Neurosurgery 2000; 47 (3 Suppl) S69-92
• 4 Morrison AW, King TT. Experiences with a translabyrinthine-transtentorial approach to the cerebellopontine angle. Technical note. J Neurosurg 1973; 38 (3) 382-390
• 5 Samii M, Ammirati M. The combined supra-infratentorial pre-sigmoid sinus avenue to the petro-clival region. Surgical technique and clinical applications. Acta Neurochir (Wien) 1988; 95 (1-2) 6-12
• 6 Al-Mefty O, Fox JL, Smith RR. Petrosal approach for petroclival meningiomas. Neurosurgery 1988; 22 (3) 510-517
• 7 Cheung SW, Jackler RK, Pitts LH, Gutin PH. Interconnecting the posterior and middle cranial fossae for tumors that traverse Meckel's cave. Am J Otol 1995; 16 (2) 200-208
• 8 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 875–876
• 9 Kawase T, Toya S, Shiobara R, Mine T. Transpetrosal approach for aneurysms of the lower basilar artery. J Neurosurg 1985; 63 (6) 857-861
• 10 Rhoton Jr AL. The cerebellopontine angle and cerebellar cranial nerves by the retrosigmoid approach. Neurosurgery 2000; 47 (3 Suppl) S93-129
• 11 Seoane E, Rhoton Jr AL. Suprameatal extension of the retrosigmoid approach: microsurgical anatomy. Neurosurgery 1999; 44 (3) 553-560
• 12 Matsushima T, Rhoton Jr AL, de Oliveira E, Peace D. Microsurgical anatomy of the veins of the posterior fossa. J Neurosurg 1983; 59 (1) 63-105
• 13 Guppy KH, Origitano TC, Reichman OH, Segal S. Venous drainage of the inferolateral temporal lobe in relationship to transtemporal/transtentorial approaches to the cranial base. Neurosurgery 1997; 41 (3) 615-619 , discussion 619–620
• 14 Sakata K, Al-Mefty O, Yamamoto I. Venous consideration in petrosal approach: microsurgical anatomy of the temporal bridging vein. Neurosurgery 2000; 47 (1) 153-160 , discussion 160–161
• 15 Rhoton Jr AL. Microsurgical anatomy of acoustic neuromas. Neurol Res 1984; 6 (1-2) 3-21
• 16 Gharabaghi A, Koerbel A, Löwenheim H, Kaminsky J, Samii M, Tatagiba M. The impact of petrosal vein preservation on postoperative auditory function in surgery of petrous apex meningiomas. Neurosurgery 2006; 59 (1) (Suppl. 01) ONS68-ONS74 , discussion ONS68–ONS74
• 17 Strauss C, Naraghi R, Bischoff B, Huk WJ, Romstöck J. Contralateral hearing loss as an effect of venous congestion at the ipsilateral inferior colliculus after microvascular decompression: report of a case. J Neurol Neurosurg Psychiatry 2000; 69 (5) 679-682
• 18 Inamasu J, Shiobara R, Kawase T, Kanzaki J. Haemorrhagic venous infarction following the posterior petrosal approach for acoustic neurinoma surgery: a report of two cases. Eur Arch Otorhinolaryngol 2002; 259 (3) 162-165
• 19 Ryu H, Yamamoto S, Sugiyama K, Yokota N, Tanaka T. Neurovascular decompression for trigeminal neuralgia in elderly patients. Neurol Med Chir (Tokyo) 1999; 39 (3) 226-229 , discussion 229–230
• 20 Ebner FH, Roser F, Shiozawa T , et al. Petrosal vein occlusion in cerebello-pontine angle tumour surgery: an anatomical study of alternative draining pathways. Eur J Surg Oncol 2009; 35 (5) 552-556
• 21 Samii M, Ammirati M, Mahran A, Bini W, Sepehrnia A. Surgery of petroclival meningiomas: report of 24 cases. Neurosurgery 1989; 24 (1) 12-17
• 22 Goel A, Nadkarni T. Basal lateral subtemporal approach for trigeminal neurinomas: report of an experience with 18 cases. Acta Neurochir (Wien) 1999; 141 (7) 711-719
• 23 Sen C. Microvascular decompression for trigeminal neuralgia. In: Starr PA, Barbaro NM, Larson PS, , eds. Neurosurgical Operative Atlas. 2nd ed. Functional Neurosurgery. New York: Thieme Medical Publishers; 2008: 79-82