Percutaneous Treatment of Meckel Cave Arachnoid Cyst: Case Report, Surgical Strategy and Literature Review

Arachnoid cysts are benign intracranial lesions. They are usually located in the middle fossa, but can be found in other locations. We present a case of symptomatic Meckel cave (MC) arachnoid cyst - a very rare location - and a treatment strategy not elsewhere described before for this condition. A 54-year-old female with trigeminal neuralgia with previous history of radiofrequency rhizotomy treatment 6 years before admission had been experiencing pain recurrence with progression, which required successive increases in carbamazepine dosage. Magnetic Resonance Imaging (MRI) showed dilatation of the right MC with extension to the petrous apex. The lesion was compatible with arachnoid cyst, and due to the worsening of the clinical condition, surgical treatment was chosen. Percutaneous puncture of the cyst through the foramen ovale with injection of intracystic fibrin sealant was performed. The patient woke up from anesthesia with pain improvement and was discharged asymptomatic the next day. After 12 months of follow-up, she remained pain-free. In the literature review, we found only eight cases reported as MC arachnoid cyst. These are likely to progress and become symptomatic owing to their communication with the subarachnoid space and a unidirectional valve mechanism. Pain improvement with this technique is probably secondary to the interruption of these mechanisms.

Endoscopic-Assisted Infralabyrinthine Approach to Petrous Apex Cholesterol Granuloma / 대한이비인후과학회지

A cholesterol granuloma is the most common primary lesion of the petrous apex, and accounts for 40% of the pathologies that arise in this region. The primary treatment for symptomatic lesions is by surgery to decompress and drain or to completely remove the lesion. Here we describe the use of infralabyrinthine approach to access a lesion through the temporal bone and completely remove it with the assistance of a 0-degree endoscope. A 43-year-old man visited our clinic for diplopia. Magnetic resonance imaging revealed a 2.3-cm cholesterol granuloma located in the left petrous apex that caused deviation of the left abducens nerve. The tumor was completely removed using the endoscopic-assisted infralabyrinthine approach; the patient is currently being followed up, and there is no evidence of disease recurrence. This case report describes the successful completion of a petrous apex cholesterol granuloma that preserved the cochlear and vestibular systems.

Cirugía endoscópica endonasal extendida a la región Petro-Clival / Ápex Petroso. Reporte de un caso y revisión de la literatura / Endonasal endoscopic surgery extended to the Petro-Clival / Petrópe region. Case report and literature review

INTRODUCCIÓN: las indicaciones de la cirugía endoscópica endonasal en el tratamiento de tumores de base de cráneo continúan expandiéndose, sobre todo para los tumores extradurales, como son los cordomas. A partir de un caso, nuestro objetivo fue revisar la literatura relevante de estos desafiantes tumores operados bajo esta técnica. CASO CLÍNICO: paciente de 59 de edad con antecedentes de depresión mayor, que comenzó con un cuadro de diplopía por compromiso del VI par izquierdo. Los estudios (CT y RM) mostraron un proceso expansivo en la región del ápex petroso. Se realizó un abordaje endoscópico extendido a la región petro-clival con resección tumoral subtotal. Buena evolución postquirúrgica con desaparición de su diplopía. El diagnóstico histológico fue de Cordoma Condroide. Se indicó radioterapia adyuvante. DISCUSIÓN: a partir del conocimiento y la experiencia en el manejo endoscópico de la patología intraselar se desarrollaron abordajes para el tratamiento de patologías que comprometen la fosa anterior, media e inclusive la fosa posterior. Actualmente, los abordajes endoscópicos, se han extendido a otras áreas de la base de cráneo que de otro modo presentan un reto técnico para la exposición a través de los abordajes transcraneales habituales. El abordaje endoscópico endonasal ofrece una ruta quirúrgica adecuada para la resección del tumor que se presenta en este caso. Las vías que pueden ser utilizados para llegar a la región petroclival a través de la acceso endonasal incluyen la medial (con o sin la movilización de ACI) y la infrapetrosa transterigoidea. En este reporte de caso se analizan las indicaciones del abordaje endoscópico endonasal basado en una revisión de la literatura. CONCLUSIÓN: el abordaje endoscópico endonasal extendido se presenta como una alternativa segura para el tratamiento de determinadas lesiones petro-clivales. Se requieren más estudios anatómicos y clínicos para establecer mejor el rol de este tipo de técnicas en el manejo de las lesiones localizadas en esta región

INTRODUCTION: indications for endoscopic endonasal surgery for the treatment of skull base tumors continue to expand, particularly for extradural tumors, such as chordomas. Based on this case report presentation, we aim to review the literature on the endoscopic technique relevant to the management of these challenging tumors. CASE REPORT: a 59 year-old woman who presented with diplopia due to left sixth nerve palsy underwent imaging studies (CT, MRI) that revealed a mainly intra-osseous expansive process of the left petrous apex. An expanded endoscopic endonasal approach to the petroclival region was performed and the tumor was subtotally resected. The patient recovered from surgery with resolved diplopia. Histopathology was compatible with chondroid chordoma. The radiation therapy was indicated after surgery. DISCUSSION: built upon the bulk experience on the treatment of intrasellar pathology, endonasal endoscopic approaches have been developed for the treatment of skull base lesions involving the anterior, middle and even posterior cranial fossae. Nowadays, the use of these techniques has spread to other areas of the skull base, which otherwise present as a formidable technical challenge for exposure through transcranial approaches. The endonasal endoscopic approach provides an adequate surgical corridor for the resection of the tumor presented in this case report. The alternative corridors that can be utilized to reach the petroclival region through the endonasal endoscopic route include the medial corridor (with or without ICA mobilization) and the transpterygoid infrapetrous corridor. In this article, we discuss the indications for the endoscopic endonasal approach for the case presented, and discuss our choice of approach based on our review of the literature. CONCLUSION: the extended endoscopic endonasal approach presents as a safe alternative for the treatment of select petroclival lesions. Further anatomical and clinical studies are required to better establish the role of the endoscopic endonasal approach for lesions located in this region

Primary study of diagnosis and treatment of huge petrous apex cholesteatoma( clinical analysis of 2 cases) / 临床耳鼻咽喉头颈外科杂志

Objective:To investigate the clinical features, operative approach and method of petrous apex chol-esteatoma, to improve the effect of operation and to reduce surgical complications. Method:Two cases of patients with giant petrous apex cholesteatoma were treated by trans labyrinth approach,one of which was successfully operated with oto-endoscope-assisted surgery. Result; No cerebrospinal fluid leakage, infection, vertigo or disequilibrium was found in the two cases after operation. Conclusion:Temporal CT and MRI are of great importance in clinical diagnosis and choice of surgical approach. Surgery by trans-labyrinth approach paves way for removing cholesteatoma thoroughly, dealing with facial nerve and repairing cerebrospinal fluid leakage. Surgery is considered to be the only way to cure petrous apex cholesteatoma, while the key procedure to prevent recurrence lies in complete removal of lesion, long-time strict follow up and regular clearance of the surgical field.

Petrous Apex Cholesterol Granuloma Presenting as Endolymphatic Hydrops: A Case Report

A petrous apex cholesterol granuloma (PACG) is the most common lesion of the petrous apex mass. Affected patients present with various symptoms such as hearing loss, vertigo, headache, tinnitus, facial spasms, and diplopia. We report the case of a 32-yr-old man with a PACG, who was first misdiagnosed with Meniere's disease. He was placed on a low-salt diet, and prescribed medication from another hospital, for several months, but the symptoms persisted and worsened. The patient presented to the emergency room complaining of left facial twitching and numbness. To rule out a central neurological lesion, temporal bone magnetic resonance imaging was carried out and a 2.5 cm mass with high signal intensity on T1- and T2-weighted imaging, without gadolinium enhancement, was found. Because of the hearing and facial problems, we drained cholesterol-bearing material via an infralabyrinthine approach using a computer aided image-guided surgical device, the BrainLAB(R). After the operation, the vertigo and hearing loss were no longer present. It is likely that the patent's Meniere's disease-like symptoms were due to the compression of the endolymphatic sac by a PACG.

New Technique for Surgery of Petrous Apex Cholesterol Granuloma

The authors present a new technique for surgery of cholesterol granuloma (CG) at the petrous apex. An epidural middle fossa approach is used to expose and remove the cyst, with silicon tube drainage into the sphenoid sinus via the anterolateral cavernous sinus triangle between the first and second divisions of the trigeminal nerve. This novel method is less invasive skull base approach to the petrous apex and very effective for minimizing recurrence of CGs within the petrous apex.

Surgical Anatomical Landmarks for Petrous Apex / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Anatomical knowledge of the petrous apex is essential to otolaryngologist to explore the skull base lesions. This study was designed to investigate the surgical anatomy of the petrous apex and the middle cranial fossa. MATERIALS AND METHODS: We dissected 32 temporal bones in order to establish the anatomical relationships of petrous apex structures. We measured distances and angles between different structures so that surgeons can rely on to work in this area. RESULTS: The results of the present study showed distances and angles of the different petrous apex structures. The angle between posterior point-foramen spinosum and porus was 90 degree. CONCLUSION: We could suggest the new indicators to identify the internal acoustic canal.

Surgical Anatomy for the Infracochlear Approach to the Petrous Apex / 대한이비인후과학회지

BACKGROUND: Infracochlear approach indroduced by Ghorayeb et al. in 1988, was performed to reach the petrous apex with the canal wall-down procedure. Giddings et al. described the transcanal infracochlear approach preserving the posterior wall of the external auditory canal for treatment of the cholesterol granuloma in the petrous apex in 1991. OBJECTIVES: Surgical anatomy for the infracochlear approach to the petrous apex was reviewed in order to understand clinical applicability of this approach. MATERIALS AND METHODS: This study was performed using 20 human cadaveric temporal bones by the microscopic dissection. Measurements were obtained between different structures to find reliable angles and distances to guide working in the petrous apex region. RESULTS: The petrous apex was entered through the fenestra between the cochlea, carotid, and jugular bulb. The mean area of the fenestrae was 11.7+/-5.5mm2. The distance from the vertical segment of the facial nerve to the petrous apex was 25.3+/-2.4mm. The angle of the approach to the petrous apex was 37.3+/-5.1degrees to the axis of the internal auditory canal. CONCLUSION: The infracochlear approach could be used to obtain the route for a drainage procedure or a biopsy at the petrous apex without damaging hearing organs and major vessels. The canal-down procedure was needed to assess the petrous apex successfully.