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Sekhar 1987
Sekhar 1987
Sekhar 1987
VeN though m a n y neoplasms involving the cranial base are benign or locally confined malignant lesions, radical resection of extensive lesions remains difficult. Reasons for this include the
location of these tumors below the base of the brain
with the possibility of retraction-related cerebral injury;
the involvement by the t u m o r of basal blood vessels,
injury to which may lead to stroke and/or death; the
involvement of cranial nerves, injury to which results
in significant functional deficits; and the potential for a
postoperative cerebrospinal fluid (CSF) fistula through
the skin, paranasal sinuses, or nasopharynx which may
be followed by meningitis and death. However, several
advances have occurred during the past decade that
permit a total or near total resection of m a n y such
488
9 neurilemoma
9 chordoma
neoplasms with a low morbidity. These advances include an improved understanding of cranial base anatomy, resulting in the introduction of new operative
approaches; the improved management of the petrous
and cavernous internal carotid artery (ICA); the preservation or reconstruction of cranial nerves involved
by the tumor; and improved cranial base reconstruction
techniques.
The cranial base is conveniently classified into anterior, middle, and posterior parts that correspond to the
respective cranial fossae. This classification system is
followed by us in this publication. Jackson and Hide ~2
have divided the middle and posterior cranial base into
three compartments: the sphenoid base, the petrous
temporal base, and the clivus. However, conceptually
TABLE 2
Tumor Pathology
No. of
Cases
benign neoplasms
angiofibroma,juvenile*
1
epidermoid cyst
2
glomus vagaletumor
1
meningiomat
5
neurilemoma, ninth cranial nervet
1
malignant cartilaginous neoplasms
chordoma*t
2
chondrosarcoma*t
1
other malignant neoplasms
adenoid cysticcarcinomat
2
basal cell carcinoma
l
squamous cell carcinomat
3
undifferentiated carcinoma(recurrent)
3
total cases
22
* In these cases an anterior extradural approach, either transbasal
or transethmoidal, was also used simultaneouslyor in a different stage
for tumor removal.
t In these cases an intradural approach, either retromastoid or
frontotemporal, was used in the same or a different stage for tumor
removal.
Preoperative Evaluation
All the patients underwent a neurological, otolaryngological, and general physical examination. Computerized tomography (CT) scanning was performed in the
axial and coronal planes using both soft-tissue and bone
algorithms. Magnetic resonance imaging (MRI) was
performed on all recent patients and was especially
Tumor Location
intracranial
middle cranial fossa
cavernous sinus
posterior fossa-cerebeUopontineangle
clivus
foramen magnum
cranial (bone involvement)
clivus (excludingbody of sphenoid)
sphenoid bone
petrous bone, medial region
petrous bone, lateral region
extracranial
orbit
ethmoid sinus
sphenoid sinus
maxillary sinus
infratemporal fossa
retropharyngeal space
parapharyngeal space
upper cervical area
nasopharynx
No. of
Cases
3
11
6
5
1
12
11
17
0
6
4
10
6
18
9
7
1
5
Staging o f Operations
When the lesion extended into the intradural compartment, surgery was planned to remove the extradural
portion of the tumor first and the remainder at a
subsequent operation (five patients). However, if there
was a considerable intracranial mass, the intradural
portion was removed first (one patient). Occasionally,
an intradural procedure was combined with an extradural procedure (Case 9). In two patients, two extradural approaches were combined.
L. N. Sekhar, et al.
FIG. 1. Diagrams showing the subtemporat-preauricular infratemporal approach to lateral and posterior
cranial base neoplasms. UpperLeft: The solid and dotted lines show the incision used for this approach.
Upper Center: The skin and subcutaneous tissues have been turned forward. The facial nerve (VII) has been
dissected from the stylomastoid foramen to the parotid gland, and its frontalis branch has been exposed beyond
the gland. The internal carotid artery (ICA), the external carotid artery, the internal jugular vein, the digastric
muscle, and the seventh, 10th, and 12th cranial nerves are exposed in the neck. SCM = sternocleidomastoid
muscle. Upper Right: The temporalis muscle has been reflected anteroinferiofly after division of the
zygomatic arch. The lateral and superior orbital rim may also be removed, but this is not shown in these
drawings. The tympanic part of the temporal bone, the bony eustachian tube, and the tensor tympani muscle
are superficial to the petrous ICA. The tumor is closely related to the petrous ICA. The mandibular (V3) and
maxillary (V2) nerves have been exposed after unroofing their bone canals. Lower Left: Early stage in the
exposure of the petrous ICA, starting at its genu and the vertical segment. Note the relationship of the sphenoid
sinus, which lies medial to the V2. Lower Right: The petrous ICA has been mobilized from the carotid canal
and displaced forward. Considerable tumor removal has taken place. The clival bone of the contralateral side
and the clival dura of the ipsilateral side are exposed. The superior orbital fissure and the orbital apex area
have been completely unroofed.
Operative Technique
Approach to the Tumor. The patient is placed in
the supine position, the head is turned 45* to the
contralateral side, and the neck is extended. The patient
490
L. N. Sekhar, et al.
this exposure. The inferior and medial surfaces of the
cavernous ICA will also be exposed in this process, and
one has to be careful not to injure the vessel. If the V2
is divided, it may be resutured together at the end of
the operation.
One may enter the posterior and inferior aspects of
the cavernous sinus by following the petrous ICA upward. Alternatively, the anterior aspect of the cavernous
sinus may be entered by following the V2 backward into
the lateral wall between the leaves of the dura, and then
entering the cavernous sinus between the ophthalmic
division of the trigeminal nerve (V~) and the V2. Entry
into the cavernous sinus is much easier when the tumor
extends from one area into the other, and the surgeon
follows the path taken by the tumor.
Extensions of the neoplasm into the orbit, maxillary
sinus, ethmoid sinus, infratemporal fossa, and retroand parapharyngeal space are easily removed by this
approach. When the tumor extends into the petrous
apex of the opposite side near or around the contralateral petrous ICA, it may also be removed by this
approach. However, this is not recommended unless
proximal control of the contralateral ICA has been
previously obtained in the neck.
Management of the Petrous and Upper Cervical
ICA. The management of the petrous and upper cervical ICA depends in part on the pathology of the
neoplasm, the presence of arterial wall invasion as determined at surgery, and the results of the preoperative
balloon-occlusion test. 28 Based on the balloon-occlusion test, patients may be divided into three categories.
Patients who develop neurological deficits during preoperative test balloon occlusion are considered to be at
high risk for stroke if the artery is permanently occluded
intraoperatively or postoperatively, or if the artery is
temporarily occluded for an extended period intraoperatively. The operative risk is therefore higher for these
patients, and nonoperative therapy should be reconsidered. If an operation is elected, a preoperative extracranial-intracranial bypass should be considered. The second group of patients includes those who tolerate test
balloon occlusion well clinically but develop a CBF
reduction in the middle cerebral artery territory to the
range of 15 to 30 ml/100 mg/min. These patients are
at moderate risk for stroke after permanent ICA occlusion but at minimal risk after prolonged temporary
occlusion. If the ICA has to be resected at operation in
a patient in this group, it should be directly reconstructed by a short saphenous vein graft. The majority
of patients fall into the third group: those without
clinical symptoms or signs during test occlusion and
who have CBF values greater than 30 ml/100 gm/min
in the middle cerebral artery distribution during the
occlusion period. Such patients will probably tolerate
permanent ICA occlusion, provided that occlusion is
performed as close to the ophthalmic artery as possible
(eliminating a stump as an embolic source) and that
careful attention is paid to intraoperative and postoperative blood pressure, blood volume, and rheology.
492
Case 6. Meningioma
This 4 1-year-old woman had undergone two previous
partial resections and radiation therapy for an extensive
493
L. N. Sekhar, et al.
FIG. 3. Magnetic resonance images in Case 13. Upper Left: Preoperative Tl-weighted sagittal image
revealing a tumor involving the ethmoid and sphenoid sinuses and the upper and mid clivus. A small lesion
created by nasopharyngeal biopsy can be seen in the ports. UpperRight: Preoperative Trweighted coronal
image showing a tumor inside both cavernous sinuses and in the supraseUar region. Lower Left: The T2weighted sagittal image after the first operation demonstrating the muscle flap (M) and no residual tumor in
this plane. Lower Right: Postoperative Tl-weighted coronal image showing blood clot within the right
cavernous sinus and residual tumor in the suprasellar region and the left cavernous sinus.
medial sphenoid wing meningioma involving the cavernous sinus and the middle cranial fossa. The tumor
continued to grow despite the radiation therapy, and
involved the orbital apex, cavernous sinus, middle fossa,
sphenoid, maxillary and clival bones, the sphenoid and
ethmoid sinuses, and the infratemporal fossa (Fig. 4
upper pair). The ICA had been occluded during a
previous operation, and the second and third cranial
nerves were nonfunctional when she presented to us. A
5-mm proptosis was present.
At the first operation the entire extradural tumor was
removed by a subtemporal extradural-preauricular infratemporal fossa approach. A rectus abdominis flap
was placed to occlude the space occupied by the tumor
and to seal off the sphenoid, ethmoid, and maxillary
494
FIG. 4. Computerized tomography scans in Case 6. Upper Pair." Preoperative contrast-enhanced axial
images, using a soft-tissue algorithm (left) and a bone algorithm (right), demonstrating a meningioma involving
the cavernous sinus, middle fossa, orbital apex, sphenoid bone, sphenoid sinus, and ethmoid sinus. Extension
of tumor into the infratemporal fossa and maxillary bone is not shown. Lower Pair." Postoperative axial
images at a higher (left) and lower (right) level illustrating the absence of tumor and the occlusion of the dead
space with temporalis muscle. The rectus abdominis muscle flap, which is now devascularized, is also shown.
L. N. Sekhar, et al.
TABLE 3
Tumor
benign neoplasms
1 juvenile angiofibroma
Operative Approach*
Extent of
Resection
Irradiation
subtemporal-infratemporal, transethmoidal
total
no
2
3
4
epidermoid cyst
epidermoid cyst
glomus vagale tumor
subtemporal-infratemporal
subtemporal-infratemporal
subtemporal-infratcmporal
total
total
total
no
meningioma
1: subtemporal-infratemporal; 2: frontotemporal;
total
yes
6
7
meningioma
meningioma
1: subtemporal-infratemporal; 2: frontotemporal
subtemporal-infratemporal, frontotemporal
approach
total
total
no
8
9
meningioma
meningioma
1: subtemporal-infratemporal; 2: frontotemporal
1: retromastoid; 2: suboccipital-Cl laminectomy;
3: subtemporal-infratemporal
subtotal
subtotal
no
total
no
total
proton
beam
external
beam
10
neurilemoma, ninth
1: retromastoid; 2: subtemporal-infratemporal
cranial nerve
malignant cartilaginous neoplasms
11
chordoma
subtemporal-infratemporal
no
no
no
no
Follow-Up Period
& Outcomet
9 mos: good, 3rd, 4th, 6th, 7th
cranial nerve paresis resolving, no recurrence
2 89yrs: good, no recurrence
1 yr: good, no recurrence
1 yr: fair, swallowing & speech
problems, no recurrence
3 yrs: good, 7th cranial nerve
palsy resolving, no recurrence
1 yr: good, no recurrence
1 yr: good, persistent loss of
2nd cranial nerve function,
no recurrence
9 mos: good, residual tumor
9 mos: good, 9th, 10th cranial
nerve paresis, residual tumor
1 89
yrs: good, no recurrence
1 89
yrs: good, no recurrence
12
chordoma
subtotal
13
chondrosarcoma
l: subtemporal-infratemporal, transethmoidal;
2: subfrontal (CSF leak); 3: frontotemporal
total
external
beam
1: subtemporal-infratemporal; 2: frontotemporal
total
yes
l: subtemporal-infratemporal; 2: frontotemporal
total
no
l: subtemporal-infratemporal; 2: frontotemporal
total
yes
partial
no
2 mos: died
total
yes
1 88
yr: good, no recurrence
subtemporal-infratemporal
l: subtemporal-infratemporal; 2: abscess drainage,
rectus abdominis flap
subtemporal-infratemporal
total
subtotal
yes
total
subtemporal-infratemporal
total
external
beam
external
beam
no
No. of
Cases
1
1
3
4
1
1
1
1
1
2
7
1
3
I
2
5
received a Teflon injection of the vocal cord and recovered a good voice and swallowing function. One
patient who has bilateral vocal cord paralysis because
of bilateral glomus vagale tumors that occurred 10 years
apart remains disabled with regard to both swallowing
and speaking.
Although 10 patients had unilateral resection of the
mandibular condyle, these patients had only temporary
problems of malocclusion and chewing, lasting 3 to 6
months postoperatively.
Discussion
L. N. Sekhar, et al.
tween the dura and the nasopharynx. The transbasal
approach does allow an extensive galeopericranial flap
reconstruction. The latter approach is primarily extramucosal and extradural, but if a dural tear should occur,
CSF leakage problems are similar to these associated
with the other anterior approaches unless adequate
reconstruction and CSF drainage are provided. The
transbasal approach allows an extensive exposure of the
ethmoid and sphenoid sinuses and the mid and lower
clivus. The exposure provided by the transethmoidal
approach is similar, but the optic nerves and orbital
apex are not quite as well exposed. The transsphenoidal
approach provides a less extensive exposure of the
sphenoid sinus and of the mid clivus than do the
previous two exposures. However, the upper clivus
(hidden behind the sella turcica) may be best exposed
by this approach. The transoral transpalatal approach
provides a shorter route to the mid and lower clivus
and the foramen magnum region than do the other
anterior approaches. However, should CSF leakage occur, the potential for grave meningeal infection is greatest with this approach.
A variety of lateral extradural approaches have been
developed to overcome some of the problems of the
anterior approaches. With the exception of the infratemporal fossa approach of Fisch and our subtemporal-infratemporal fossa approach, they all share the
disadvantage of limited exposure. The translabyrinthine approach is popularly used for the removal of
small and medium-sized acoustic neuromas, and may
also be used in combination with the retromastoid
intradural approach. 5'6 The transcochlear approach is a
further extension of the translabryrinthine technique,
but with the removal of the cochlea. Such an approach
can provide a restricted exposure of the mid clivus, and
has been used for the removal of intradural lesions such
as meningiomas.9'~~With both of these approaches the
patient's hearing is destroyed, and with the transcochlear approach a prolonged facial paralysis always results,
often with incomplete recovery and synkinesis. The
infratemporal approach of Fisch has been divided into
Types A, B, and C. 3-5 The Type A and B approaches
involve a retroauricular incision with transection of the
external ear canal, removal of the middle ear structures,
and displacement of the facial nerve from the fallopian
canal. These two approaches have been used for lesions
involving jugular bulb, facial recess, hypotympanic and
apical areas of the petrous temporal bone, and the lower
clivus. Examples of tumors removable by these approaches include glomus jugulare tumors, jugular foramen neurilemomas, and petrous apex epidermoid tumors. A permanent conductive hearing loss always
results, and a prolonged temporary facial paralysis generally occurs, followed usually by incomplete recovery
and synkinesis of facial movements. The Type C infratemporal fossa approach utilizes a retroauricular incision but does not involve facial nerve displacement; a
conductive hearing loss always follows. This technique
has been used by Fisch for lesions in the nasopharyn498
17.
18.
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499