The extended retrosigmoid approach for neoplastic lesions in the posterior fossa: technique modification |
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Authors: | Shaan M Raza Alfredo Quinones-Hinojosa |
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Institution: | (1) Department of Neurosurgery, The Johns Hopkins Neuro-Oncology Surgical Outcomes Research Laboratory, Johns Hopkins School of Medicine, Baltimore, MD, USA;(2) Department of Neurosurgery and Oncology, Brain Tumor Stem Cell Laboratory, 1550 Orleans Street, Cancer Research Building II Room 247, Baltimore, MD 21231, USA; |
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Abstract: | Approaches to the cerebellar-pontine angle and petroclival region can be challenging due to intervening eloquent neurovascular
structures and cerebellar retraction required to view this anatomic compartment with the standard retrosigmoid technique.
As previously described 11], the extended retrosigmoid provides additional access to space ventral to the brainstem through mobilization of the sigmoid
sinus. We report our further experience and modifications of this approach for neoplastic pathology. The standard craniotomy
is utilized, and the burr holes are placed slightly beyond the transverse sinus as well as the transverse–sigmoid junction
and down towards the foramen magnum, as low as possible. Another burr hole is placed over the cerebral hemisphere to facilitate
the dural dissection below the bone flap and over the transverse and sigmoid sinuses. We then perform a standard retrosigmoid
craniotomy with a craniotome and the transverse and sigmoid sinuses are skeletonized. Consequently, the sigmoid sinus can
then mobilized anteriorly to provide an unobstructed view in line with the petrous bone, while exposure of the transverse
sinus provides access to the tentorium. Fifteen patients (March 2006–July 2008) underwent this approach to manage neoplastic
lesions, including five meningiomas, three schwannomas, one epidermoid, and four intra-axial metastatic lesions. The nine
extra-axial lesions were predominantly in the cerebellar-pontine angle with extension medial to the seventh/eighth nerve complex
to the petroclival region. Gross total resection was obtained in all patients. The primary complication due to the exposure
was a clinically asymptomatic sigmoid sinus thrombosis in one patient. Requiring a fundamental change in the management of
the venous sinuses, the extended retrosigmoid craniotomy permits mobilization of the sigmoid and transverse sinuses. In this
process, the entire cerebellar-pontine angle extending from the tentorium to the foramen magnum can be visualized with minimal
cerebellar retraction. This technical modification over the standard retrosigmoid approach may provide a useful advantage
to neurosurgeons dealing with these complex lesions. |
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