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Operative Neurosurgery (Hagerstown, Md.) Dec 2023This approach is intended for tumors centered in the jugular foramen with extensions between intracranial and extracranial spaces, possible spread to the middle ear, and...
INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE
This approach is intended for tumors centered in the jugular foramen with extensions between intracranial and extracranial spaces, possible spread to the middle ear, and variable bony destruction. 1,2.
ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT
Jugular foramen paragangliomas are complex lesions that usually invade and fill related venous structures. They present complex relationships with skull base neurovascular structures as internal carotid artery, lower cranial nerves (CNs), middle ear, and mastoid segment of facial nerve. In this way, it is essential to perform an adequate preoperative vascular study to evaluate sinus patency and the tumor blood supply, besides a computed tomography scan to depict bone erosion.
ESSENTIAL STEPS OF THE PROCEDURE
Mastoidectomy through an infralabyrinthine route up to open the lateral border of jugular foramen, allowing exposure from the sigmoid sinus to internal jugular vein. Skeletonization of facial canal without exposure of facial nerve is performed and opening of facial recess to give access to the middle ear in way of a fallopian bridge technique. 2-10.
PITFALLS/AVOIDANCE OF COMPLICATIONS
If there is preoperative preservation of lower CN function, it is important to not remove the anteromedial wall of the internal jugular vein and jugular bulb. In addition, facial nerve should be exposed just in case of preoperative facial palsy to decompress or reconstruct the nerve.
VARIANTS AND INDICATIONS FOR THEIR USE
Variations are related mainly with temporal bone drilling depending on the extensions of the lesion, its source of blood supply, and preoperative preservation of CN function.Informed consent was obtained from the patient for the procedure and publication of his image.Anatomy images were used with permission from:• Ceccato GHW, Candido DNC, and Borba LAB. Infratemporal fossa approach to the jugular foramen. In: Borba LAB and de Oliveira JG. Microsurgical and Endoscopic Approaches to the Skull Base. Thieme Medical Publishers. 2021.• Ceccato GHW, Candido DNC, de Oliveira JG, and Borba LAB. Microsurgical Anatomy of the Jugular Foramen. In: Borba LAB and de Oliveira JG. Microsurgical and Endoscopic Approaches to the Skull Base. Thieme Medical Publishers. 2021.
Topics: Humans; Jugular Foramina; Skull Base; Glomus Jugulare Tumor; Temporal Bone; Cranial Nerves
PubMed: 37350587
DOI: 10.1227/ons.0000000000000775 -
Surgical and Radiologic Anatomy : SRA Feb 2020In the literature, there is a lack of complete description of dural arteries of the dorsoclival area with contradictory data. However, dorsoclival area is a site of...
OBJECTIVE
In the literature, there is a lack of complete description of dural arteries of the dorsoclival area with contradictory data. However, dorsoclival area is a site of tumors and vascular malformation or the skull base. That is why, the knowledge of dural arteries is very important.
METHODS
Using a colored silicone mix preparation, fifteen sides of eight cranial bases were studied using 4-20× magnification of the surgical microscope.
RESULTS
Dorsoclival area is supplying by three arterial complexes, internal carotid artery complex with always the dorsal meningeal artery for the superior two-third of the clivus, medial clival artery for the dorsum sellae, the external carotid artery complex with the hypoglossal and jugular branches of the ascending pharyngeal artery for the inferior one-third of the clivus, and the vertebral artery complex with the anterior meningeal artery for the most inferior part of the clivus and the anterior edge of the foramen magnum. Moreover, there are many anastomoses between those three arterial complexes at this area.
CONCLUSION
Dural arterial supply of the dorsoclival area is very opulent. Its knowledge is important for surgical approaches and endovascular procedures.
Topics: Cadaver; Carotid Artery, Internal; Cranial Fossa, Posterior; Dura Mater; Female; Humans; Male; Meningeal Arteries
PubMed: 31486864
DOI: 10.1007/s00276-019-02320-w -
World Neurosurgery Sep 2021Hemangiopericytomas (HPCs) and solitary fibrous tumors (SFTs) are rare tumors of mesenchymal origin. Here, the authors present a rare case of anaplastic HPC in the...
BACKGROUND
Hemangiopericytomas (HPCs) and solitary fibrous tumors (SFTs) are rare tumors of mesenchymal origin. Here, the authors present a rare case of anaplastic HPC in the jugular foramen (JF). The authors also conduct a systematic review of the literature to examine the current fund of knowledge on JF HPC/SFTs.
METHODS
A systematic MEDLINE search was conducted using key words "hemangiopericytoma" OR "solitary fibrous tumor" AND "jugular foramen" OR "extracranial" OR "skull base." Clinicopathologic characteristics and outcomes of the present case were reviewed and compared with those in the literature.
RESULTS
A 41-year-old male, who had undergone stereotactic radiation therapy 6 years ago for a presumed glomus jugulare tumor, presented to our institution with worsening dysphagia, hoarseness, persistent tongue weakness, and radiographic evidence of tumor progression. The patient underwent uncomplicated gross total resection with sacrifice of the infiltrated hypoglossal nerve. Histopathologic evaluation revealed anaplastic HPC/SFT (World Health Organization grade III). Review of the literature yielded 9 additional cases of JF HPC/SFT in 5 males (56%) and 4 females (44%), with a mean age of 49.6 years old. Patients commonly presented with pain (37.5%) and lower cranial nerve deficits (100%). Preoperative diagnoses included glomus jugulare (n = 2) or JF schwannomas (n = 3). All patients underwent microsurgical resection of the lesion, except for 1 who refused all treatment after diagnostic biopsy.
CONCLUSION
The authors present the only reported case of anaplastic HPC of the JF. The illustrative case and those found on systematic review of the literature highlight the importance of tissue diagnosis and appropriate management.
Topics: Adult; Diagnostic Errors; Glomus Jugulare; Hemangiopericytoma; Humans; Jugular Foramina; Magnetic Resonance Imaging; Male; Radiosurgery
PubMed: 34182175
DOI: 10.1016/j.wneu.2021.06.094 -
World Neurosurgery Jul 2022Approaches to the jugular foramen can be challenging. Adding to this difficulty is the potential for a bony septation to occur in the foramen thus subdividing its...
INTRODUCTION
Approaches to the jugular foramen can be challenging. Adding to this difficulty is the potential for a bony septation to occur in the foramen thus subdividing its contents. Although such bony septations in the jugular foramen are known, the anatomic details of these structures have not been studied well. Therefore, the present anatomic study was performed.
METHODS
One hundred adult human skulls (200 sides) underwent evaluation for the presence or absence of a bony septation within the jugular foramen. The source, morphology, and size were all documented. A classification scheme was developed to better describe the varied types of morphology of the jugular foramen bony septa. Select bony septations were submitted to histologic analysis using hematoxylin and eosin and Masson's trichrome.
RESULTS
Bony bridges were found on 8.5% of sides. These were bilateral in 3% of skulls. Eight (47%) were incomplete (type I). Nine sides (53%) were found to have completely articulated bony bridges (type II) and these had articulation between the bony processes as either touching (type IIa), joint-like (type IIb), or completely fused (type IIc) morphologies. Multiple septa were observed on 2.5% of sides and these were classified as type III septa. Histologically, both incomplete and complete septa were found to be composed of normal bone tissue.
CONCLUSIONS
Our study found significant variations regarding the bony septa of the jugular foramen. Knowledge of this anatomy can be useful for preoperative planning and intraoperative navigation with approaches to the skull base that target pathology of the jugular foramen.
Topics: Adult; Humans; Jugular Foramina; Jugular Veins; Skull; Skull Base
PubMed: 35398325
DOI: 10.1016/j.wneu.2022.04.010 -
Operative Neurosurgery (Hagerstown, Md.) Nov 2021Owing to their scarcity, location, and intricate neurovascular associations, jugular fossa tumors are among the most challenging pathologies encountered by the...
Owing to their scarcity, location, and intricate neurovascular associations, jugular fossa tumors are among the most challenging pathologies encountered by the neurosurgeon.1 While paragangliomas originate within and often occlude the jugular bulb, schwannomas and meningiomas are extra-bulbar and typically do not impede venous flow.2 Schwannomas typically arise from an extradural origin, expanding the jugular foramen.3-5 Meningiomas are intradural and cause hyperostosis of the jugular tubercle.6 We described and have been exposing and resecting jugular fossa tumors through a presigmoid suprabulbar infralabyrinthine window6 that has been detailed in cadaveric studies.7,8 This approach maintains the patency of the jugular bulb without breaching the labyrinths or manipulating the facial nerve. It is applicable to cases with partially impaired hearing and intact lower cranial nerves. The carotid artery can be identified by neuronavigation and micro-Doppler ultrasonography. This approach provides a direct lateral trajectory with a short distance to the jugular fossa and cerebellopontine angle. Early exposure and central debulking of the tumor minimize manipulation of the exquisitely sensitive lower cranial nerves. The distal aspect of these tumors can be removed with endoscopic assisted techniques.9 The first patient is a 49-yr-old woman with a previously irradiated schwannoma who presented with worsening neurologic deficits-an extradural suprabulbar approach was used to resect this tumor. The second patient is a 27-yr-old woman with an enlarging meningioma and associated neurological dysfunction; this tumor was resected using the suprabulbar approach with opening of the presigmoid dura. Both patients have consented to surgery and publication of images. Image at 2:27 and 6:38 reprinted from Arnautović et al, with permission from JNSPG. Image at 2:50 and 6:45 ©Ossama Al-Mefty 1997, reused with permission.
Topics: Facial Nerve; Female; Humans; Meningeal Neoplasms; Meningioma; Neurilemmoma; Neuronavigation
PubMed: 34670274
DOI: 10.1093/ons/opab339 -
Journal of Neurosurgery Oct 2022The jugular foramen (JF) is one of the most complex and challenging skull base regions to approach surgically. The extreme medial approach to access the JF provides the...
OBJECTIVE
The jugular foramen (JF) is one of the most complex and challenging skull base regions to approach surgically. The extreme medial approach to access the JF provides the approach angle from an anterior direction and does not require dissection and sacrifice of the jugular bulb (JB) to reach the pars nervosa. The authors compared the Fisch type A approach to the extreme medial approach to access the JF and evaluated the usefulness of the extreme medial approach.
METHODS
This study was performed at the Anatomical Laboratory for Visuospatial Innovations in Otolaryngology and Neurosurgery of The Ohio State University. For the comparison of surgical maneuverability and visualization, two angles were measured: 1) the angle of attack (AoA), defined as the widest angle of movement achieved with a straight dissector; and 2) the angle of endoscopic exposure (AoEE), defined as the widest angle of movement in the nasal cavity. The differences in eustachian tube (ET) management, approach angle, surgical maneuverability, and surgical application of the Fisch type A approach to the extreme medial approach were compared.
RESULTS
There was no difference between ET mobilization and transection regarding cranial-caudal (CC) or medial-lateral (ML) AoA (p = 0.646). The CC-AoA of the Fisch type A approach was significantly wider than the CC-AoA of the extreme medial approach (p = 0.001), and the CC-AoEE was significantly wider than the CC-AoA of the extreme medial approach (p < 0.001). There was no significant difference between the CC-AoA of the Fisch type A approach and the CC-AoEE. The ML-AoA of the Fisch type A approach was significantly wider than the ML-AoA of the extreme medial approach (p = 0.033), and the ML-AoEE was significantly wider than ML-AoA in the extreme medial approach (p < 0.001). The ML-AoEE was significantly wider than the ML-AoA in the Fisch type A approach (p = 0.033).
CONCLUSIONS
The surgical maneuverability of the extreme medial approach was not inferior to that of the Fisch type A approach. The extreme medial approach can provide excellent surgical field visualization, while preserving the JB. Select cases of chordomas, chondrosarcomas, and JF schwannomas should be considered for an extreme medial approach. These two approaches are complementary, and a case-by-case detailed analysis should be conducted to decide the best approach.
PubMed: 35061978
DOI: 10.3171/2021.11.JNS212065 -
Brazilian Journal of Otorhinolaryngology 2020The anatomical complexity of the jugular foramen makes surgical procedures in this region delicate and difficult. Due to the advances in surgical techniques, approaches...
INTRODUCTION
The anatomical complexity of the jugular foramen makes surgical procedures in this region delicate and difficult. Due to the advances in surgical techniques, approaches to the jugular foramen became more frequent, requiring improvement of the knowledge of this region anatomy.
OBJECTIVE
To study the anatomy of the jugular foramen, internal jugular vein and glossopharyngeal, vagus and accessory nerves, and to identify the anatomical relationships among these structures in the jugular foramen region and lateral-pharyngeal space.
METHODS
A total of 60 sides of 30 non-embalmed cadavers were examined few hours after death. The diameters of the jugular foramen and its anatomical relationships were analyzed.
RESULTS
The diameters of the jugular foramen and internal jugular vein were greater on the right side in most studied specimens. The inferior petrosal sinus ended in the internal jugular vein up to 40mm below the jugular foramen; in 5% of cases. The glossopharyngeal nerve exhibited an intimate anatomical relationship with the styloglossus muscle after exiting the skull, and the vagal nerve had a similar relationship with the hypoglossal nerve. The accessory nerve passed around the internal jugular vein via its anterior wall in 71.7% of cadavers.
CONCLUSION
Anatomical variations were found in the dimensions of the jugular foramen and the internal jugular vein, which were larger in size on the right side of most studied bodies; variations also occurred in the trajectory and anatomical relationships of the nerves. The petrosal sinus can join the internal jugular vein below the foramen.
Topics: Accessory Nerve; Adult; Aged; Aged, 80 and over; Anatomic Variation; Dissection; Female; Glossopharyngeal Nerve; Humans; Jugular Foramina; Jugular Veins; Male; Middle Aged; Neck; Vagus Nerve
PubMed: 30348503
DOI: 10.1016/j.bjorl.2018.09.004 -
Journal of Neurological Surgery. Part... Feb 2021Surgical removal of large jugular foramen schwannomas with intra- and extracranial extension is challenging. The treatment goal is a gross total resection of the tumor...
Surgical removal of large jugular foramen schwannomas with intra- and extracranial extension is challenging. The treatment goal is a gross total resection of the tumor without causing surgical complications, including facial nerve paresis, hearing disturbance, dysphagia, hoarseness, and cerebrospinal fluid (CSF) leakage, in addition to the brain stem injury. We present a surgical video in a patient with a dumbbell-shaped glossopharyngeal schwannoma. The combination of posterior fossa craniotomy, mastoidectomy, and unroofing of the jugular foramen with high cervical exposure was selected. Although transposition of the mastoid segment of the facial nerve provides an excellent surgical corridor, it may affect normal facial nerve function. Sufficient drilling of the infralabyrinthine, retrofacial area of the mastoid without facial nerve transposition is important for the safe gross total removal of the tumor. Subcapsular removal behind the jugular vein is also important for preservation of the lower cranial nerve functions. The patient underwent a gross total removal of the tumor ( Figs. 1 and 2 ). Facial nerve function was preserved and hearing disturbance improved. Although dysphagia and hoarseness complicated postoperatively, he became able to take foods orally 16 days after the surgery. In summary, successful removal of a large dumbbell-shaped jugular foramen tumor can be completed via infralabyrinthine, retrofacial, and transjugular approach without facial nerve transposition. The link to the video can be found at: https://youtu.be/U4CwOW78id4 .
PubMed: 33717822
DOI: 10.1055/s-0040-1705167