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Journal of Clinical Medicine Dec 2023Our objective is the description of the technique of vagus nerve stimulation in carotid triangle in order to monitor the recurrent laryngeal nerve (RLN) during thyroid...
OBJECTIVE
Our objective is the description of the technique of vagus nerve stimulation in carotid triangle in order to monitor the recurrent laryngeal nerve (RLN) during thyroid and parathyroid surgery.
METHODS
We stimulated the vagus nerve in the carotid triangle during 150 thyroid or parathyroid surgeries using a monopolar electromyography electrode inserted under the mastoid process towards the jugular foramen as a cathode, and using another subdermal electrode in the mastoid as an anode. Another complementary method of vagus stimulation was achieved with a pair of subdermal electrodes, placing the cathode at the mandibular angle and the anode at the mastoid.
RESULTS
In all patients, compound muscle action potential (CMAP) was recorded in the vocal cords with both stimulation techniques, allowing semi-continuous monitoring to be carried out. Intraoperative lesions were detected in 16 of the cases; 9 of them were transient with CMAP recovery achieved when modifying surgical maneuvers.
CONCLUSIONS
Vagus nerve stimulation in the carotid triangle is a reliable technique for monitoring the RLN in thyroid surgery. Vagus nerve stimulation in the carotid triangle is effective and safe for RLN monitoring, and it is a clear alternative to direct continuous stimulation of the nerve that by contrast requires its dissection in the carotid sheath.
PubMed: 38202109
DOI: 10.3390/jcm13010102 -
Neurosurgical Review Dec 2023The mastoid foramen (MF) is located on the mastoid process of the temporal bone, adjacent to the occipitomastoid suture or the parietomastoid suture, and contains the...
The mastoid foramen (MF) is located on the mastoid process of the temporal bone, adjacent to the occipitomastoid suture or the parietomastoid suture, and contains the mastoid emissary vein (MEV). In retrosigmoid craniotomy, the MEV has been used to localize the position of the sigmoid sinus and, thus, the placement of the initial burr hole. Therefore, this study aimed to examine the exact location and variants of the MF and MEV to determine if their use in localizing the sigmoid sinus is reasonable. The sample in this study comprised 22 adult dried skulls (44 sides). MF were identified and classified into five types based on location, prevalence, whether they communicated with the sigmoid sinus and exact entrance into the groove of the sigmoid sinus. The diameters and relative locations of the MF in the skull were measured and recorded. Finally, the skulls were drilled to investigate the course of the MEV. Additionally, ten latex-injected sides from human cadavers were also dissected to follow the MEV, especially in cases with more than one vein. We found that type I MFs (single foramen) were the most prevalent (50%). These MFs were mainly located on the occipitomastoid suture; only one case on the right side was adjacent to the parietomastoid suture. Type II (paired foramina) was the second most prevalent (22.73%), followed by type III (13.64%), type 0 (9.09%), and type IV (4.55%). The diameter of the external opening in a connecting MF (2.43 ± 0.79) was twice that of a non-connecting MF (1.14 ± 0.56). Interestingly, on one side, two MFs on the external surface shared a single internal opening; the MEV bifurcated. MFs followed three different courses: ascending, almost horizontal, and descending. Regardless of how many external openings there were for the MF, these all ended at a single opening in the groove for the sigmoid sinus. For cadaveric specimens with multiple MEVs, all terminated in the sigmoid sinus as a single vein, with the more medial veins terminating more medially into the sinus. Based on our study, the MF/MEV can guide the surgeon and help localize the deeper-lying sigmoid sinus. Knowledge of this anatomical relationship could be an adjunct to neuronavigational technologies.
Topics: Adult; Humans; Mastoid; Skull; Cranial Sinuses; Craniotomy; Jugular Veins
PubMed: 38110768
DOI: 10.1007/s10143-023-02229-4 -
Head & Neck Mar 2024This study aimed to validate the feasibility of an endoscopic endonasal combined transoral medial approach for treating lesions in the nasopharynx, parapharyngeal space...
OBJECTIVE
This study aimed to validate the feasibility of an endoscopic endonasal combined transoral medial approach for treating lesions in the nasopharynx, parapharyngeal space (PPS), and jugular foramen.
METHODS
Anatomical and imaging information of six patients who underwent surgery via this approach were reviewed and analyzed.
RESULTS
The feasibility and advantages of the endoscopic endonasal combined transoral medial approach, which uses an inside-to-outside medial surgical corridor, were identified. Total resection was achieved in 3 cases with benign tumors. Safe resection margins were obtained in 2 cases with recurrent nasopharyngeal carcinoma (NPC). Pathological biopsy of NPC lesion between the Eustachian tube and arterial sheath was achieved. The internal carotid artery (ICA) was accurately located and protected in all cases and no complications occurred.
CONCLUSION
Lesions in the nasopharynx, PPS, and jugular foramen can be directly assessed via this approach. The ICA can be well identified during the surgery.
Topics: Humans; Parapharyngeal Space; Jugular Foramina; Neoplasm Recurrence, Local; Nasopharynx; Nasopharyngeal Neoplasms
PubMed: 38095125
DOI: 10.1002/hed.27596 -
Operative Neurosurgery (Hagerstown, Md.) Dec 2023The retrosigmoid intradural suprameatal approach is mostly indicated for tumors in the cerebellopontine angle extending toward the Meckel cave and supratentorial...
INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE
The retrosigmoid intradural suprameatal approach is mostly indicated for tumors in the cerebellopontine angle extending toward the Meckel cave and supratentorial regions, most frequently meningiomas and schwannomas. This approach was first established by the senior author in 1982.
ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT
Nervous structures: cranial nerves III to XII, cerebellum, and brainstem. Vascular structures: anterior inferior cerebellar artery, posterior inferior cerebellar artery, superior cerebellar artery, basilar artery, vertebral artery, transverse, sigmoid, and petrous sinus, petrosal vein/veins, basilar plexus, and the mastoid emissary vein. Bony structures: petrous bone with internal auditory canal, jugular foramen and suprameatal tubercle, petrous apex, dorsum sellae, and posterior clinoid process. Structures within the petrous bone: vestibule, semicircular canals, and jugular bulb.
ESSENTIALS STEPS OF THE PROCEDURE
After a suboccipital retrosigmoid craniectomy in the semisitting position and debulking of the tumor mass in the cerebellopontine angle, extension is achieved by drilling suprameatal tubercle above cranial nerve VII and VIII toward the petrous apex. The extent of bone drilling is tailored for each patient.
PITFALLS/AVOIDANCE OF COMPLICATIONS
Avoid damage to cranial nerves, arteries, and veins during drilling, dissection, and tumor removal or by retraction.
VARIANTS AND INDICATIONS FOR THEIR USE
In case of extreme supratentorial extensions laterally and dorsally, the opening of the tentorium may be helpful. For inferior extensions toward the upper spinal canal, opening of the foramen magnum and hemilaminectomy of C1 may be necessary.The patient consented to the procedure and to the publication of his/her image. Institutional logo in title slide, © 2023, INI Hannover. Used with permission.
PubMed: 38084947
DOI: 10.1227/ons.0000000000001030 -
Journal of Neurosurgery. Case Lessons Dec 2023Jugular foramen dural arteriovenous fistulas (DAVFs) are rare and challenging lesions. Described methods of treatment include embolization and microsurgical...
BACKGROUND
Jugular foramen dural arteriovenous fistulas (DAVFs) are rare and challenging lesions. Described methods of treatment include embolization and microsurgical disconnection through a far lateral transcondylar approach. The authors present the case of a Borden type III jugular foramen DAVF, which was treated with a novel, less invasive retrosigmoid approach with intradural skeletonization and packing of the sigmoid sinus.
OBSERVATIONS
The patient presented with headache and visual field deficit. Neuroimaging demonstrated a right temporal intracerebral hematoma with mass effect. This was due to a Borden type III jugular foramen DAVF with cortical venous reflux into the vein of Labbe secondary to recanalization of a previously thrombosed sigmoid sinus. Microsurgical disconnection was performed via a retrosigmoid approach, in which the sigmoid sinus was identified intradurally at the jugular foramen. The sigmoid sinus was isolated by drilling at the pre- and retrosigmoid spaces to permit packing and clip ligation. Postoperative angiography revealed complete occlusion of the DAVF.
LESSONS
Jugular foramen DAVFs are rare entities, which have been traditionally treated through a far lateral transcondylar approach. An intradural retrosigmoid approach is a safe, less invasive alternative, which involves less soft tissue and bony dissection and does not have the associated morbidity of craniocervical instability and hypoglossal neuropathy.
PubMed: 38079627
DOI: 10.3171/CASE23549 -
La Clinica Terapeutica 2023The present study aimed at determining the incidence of sternal foramina in adult dry bones of North Indian descent. We also aimed to determine the number, precise... (Observational Study)
Observational Study
OBJECTIVES
The present study aimed at determining the incidence of sternal foramina in adult dry bones of North Indian descent. We also aimed to determine the number, precise location of the sternal foramina with a standard reference point which might have considerable importance with regard to procedures involving sternal puncture.
METHODS
This cross sectional descriptive study was conducted on 72 dry adult human sternums. Various measurements in relation to the sternal foramina were taken with a non-stretchable measuring tape and digital vernier calliper and expressed as: [A]-total sternal length, [B]-distance between the jugular notches to the foramen, [C]-distance between the angle of Louis to the foramen and [D]-distance of the foramen from the mid sternal plane. Statistical analysis was performed with Microsoft Excel version 2019. A p-value of <0.05 was considered significant.
RESULTS
We found 6.94% (5 out of 72 sternums) incidence of sternal foramina which corroborates well with the existing literature. Mean sternal length was 127.7 ± 09 mm. The mean distance of the foramina from suprasternal notch, sternal angle and from the median plane were 118.12 ± 0.3 mm, 116.7 mm and 2.4 mm respectively. Incidence of sternal foramina was almost similar to previously reported studies.
CONCLUSIONS
The precise knowledge about the expected location of sternal foramina is imperative to avoid intra-thoracic visceral injury during commonly performed acupuncture needle insertion and while doing bone marrow aspiration for diagnostic evaluation.
Topics: Adult; Humans; Clinical Relevance; Cross-Sectional Studies; Knowledge; Neck; Research Design
PubMed: 38048113
DOI: 10.7417/CT.2023.5017 -
Journal of Neurosurgery May 2024Jugular foramen schwannomas (JFSs) are rarely seen, benign tumors with slow growth. Today, management options for JFSs include observation, surgery, and radiation....
OBJECTIVE
Jugular foramen schwannomas (JFSs) are rarely seen, benign tumors with slow growth. Today, management options for JFSs include observation, surgery, and radiation. However, the optimal treatment strategy remains controversial. Stereotactic radiosurgery serves as a minimally invasive alternative or adjuvant therapeutic regimen of microsurgery. Gamma Knife radiosurgery is suitable for patients with JFS who have small- and medium-sized tumors and normal cranial nerve (CN) function. Hypofractionated stereotactic radiotherapy (HSRT) offers a potential radiobiological advantage and may result in better preservation of normal structures compared to single-fraction stereotactic radiosurgery. The aim of the article was to review the clinical and radiographic outcomes of patients with JFS who were treated using HSRT.
METHODS
The authors retrospectively analyzed 74 patients with JFS who received HSRT between January 2009 and January 2020 in the authors' center. Among them, 53 patients were newly diagnosed with JFS, 19 patients had a previous history of microsurgical resection, and the other 2 patients underwent CyberKnife because of tumor recurrence after Gamma Knife radiosurgery. A total of 73 patients had preexisting CN symptoms and signs. The median tumor volume was 14.8 cm3 (range 0.5-41.2 cm3), and most of them (70.3%) were ≥ 10 cm3. The radiation dose regimen was prescribed depending on the tumor size, and more fractions were used in larger tumors. The median margin doses prescribed were 18.2 Gy/2 fractions, 21.0 Gy/3 fractions, and 21.6 Gy/4 fractions.
RESULTS
The median follow-up was 103 months (range 18-158 months). After treatment, 42 (56.8%) patients had tumor regression, 27 (36.5%) patients had stable tumors, and 5 (6.8%) experienced tumor progression. Among them, MRI revealed that 1 patient had a complete response. Three patients received surgery at a median of 25 months because of tumor progression. One patient underwent ventriculoperitoneal shunt insertion for hydrocephalus that developed after HSRT independent of tumor progression. The 5-year progression-free survival rate was 93.2%. Preexisting cranial neuropathies improved in 46 patients, remained stable in 14, and worsened in 14.
CONCLUSIONS
HSRT proved to be a safe and effective primary or adjuvant treatment strategy for JFSs, although 14 patients (18.9%) experienced some degree of delayed symptomatic deterioration posttreatment. This therapeutic option was demonstrated to provide both excellent tumor control and improvement in CN function.
Topics: Humans; Radiosurgery; Male; Female; Middle Aged; Adult; Neurilemmoma; Retrospective Studies; Aged; Treatment Outcome; Robotic Surgical Procedures; Radiation Dose Hypofractionation; Young Adult; Jugular Foramina; Adolescent; Follow-Up Studies; Aged, 80 and over
PubMed: 37976497
DOI: 10.3171/2023.8.JNS231026 -
Operative Neurosurgery (Hagerstown, Md.) Apr 2024The infratemporal fossa (ITF) is a complex region bounded by the temporal bone, maxilla, sphenoid, pterygoid plates, and mandibular ramus. Containing a high density of...
BACKGROUND AND OBJECTIVES
The infratemporal fossa (ITF) is a complex region bounded by the temporal bone, maxilla, sphenoid, pterygoid plates, and mandibular ramus. Containing a high density of neurovascular and musculoskeletal structures, the ITF can house a number of pathologies, and access is challenging. The ITF approach and its variations can be challenging due to complex anatomy and unfamiliarity by many surgeons. The objective of this study was to present a step-by-step 3-dimensional anatomic dissection for the classic Fisch Type A and modified ITF approach from the surgeon's perspective.
METHODS
Six sides of 3 formalin-fixed latex-injected specimens were dissected under microscopic magnification (JRD and AMN). Standard Fisch Type A and modified ITF approaches were performed on contralateral sides of each specimen. Representative high-quality 3-dimensional photography was performed for each key step.
RESULTS
The ITF approach affords excellent access to the posterior ITF and jugular foramen. Modifications to this approach include preservation of the ear canal and limiting facial nerve transposition, thus limiting morbidity while generally still providing sufficient access to key anatomic structures.
CONCLUSION
The ITF approach provides access to the lateral skull base for jugular foramen paraganglioma and other lesions. Modifications of the classic Fisch Type A technique can be used to access pathologies in this region without sacrificing conductive hearing or facial nerve function. Three dimensional operatively oriented neuroanatomy dissections provide surgeons with a valuable resource for learning this complex surgical approach.
Topics: Humans; Infratemporal Fossa; Jugular Foramina; Skull Base; Dissection; Neurosurgical Procedures
PubMed: 37976145
DOI: 10.1227/ons.0000000000000996 -
Operative Neurosurgery (Hagerstown, Md.) Mar 2024Endoscopic endonasal far-medial approach provides an effective and safe corridor to access the parasagittal structures of the lower clivus such as the medial jugular...
INDICATIONS CORRIDOR AND LIMITS OF EXPOSURE
Endoscopic endonasal far-medial approach provides an effective and safe corridor to access the parasagittal structures of the lower clivus such as the medial jugular tubercle (JT) and occipital condyle (OC) for lesions that displace neurovascular structures laterally.
ANATOMIC ESSENTIALS NEED FOR PREOPERATIVE PLANNING AND ASSESSMENT
Parapharyngeal internal carotid arteries (ICAs) run posterolateral to the eustachian tubes and lateral to the OC. The supracondylar groove is a superficial landmark for the hypoglossal canal, which divides the lateral extension of clivus into the JT and OC.
ESSENTIAL STEPS OF THE PROCEDURE
Typically, approach starts with opening of the sphenoid sinus to localize the paraclival ICA. An "inverted U" rhinopharyngeal (RP) flap exposing the supracondylar groove and lower clivus. Doppler and navigation can confirm the course of the ICA. Drilling is started in the midline in the lower clivus and extended laterally to expose the hypoglossal canal, JT, and OC.
PITFALLS/AVOIDANCE OF COMPLICATIONS
Neurovascular injuries can be avoided by using intraoperative Doppler and nerve stimulator. Multilayer reconstruction with vascularized nasoseptal (NSF) and RP flaps minimize postoperative cerebrospinal fluid leak.
VARIANTS AND INDICATIONS FOR THEIR USE
The contralateral transmaxillary approach provides an increased angle of access behind foramen lacerum and the petrous ICA.The endoscopic endonasal far-medial approach can be used for a variety of pathologies, including petroclival or JT meningiomas, chordomas and chondrosarcomas, and hypoglossal schwannomas, inferiorly extending cholesterol granulomas and even rare, ventral posterior inferior cerebellar artery aneurysms.The patients consented to the procedure.
Topics: Humans; Skull Base; Cadaver; Nose; Endoscopy; Cranial Fossa, Posterior
PubMed: 37917886
DOI: 10.1227/ons.0000000000000970