A Comparison between the Kawase and Extended Retrosigmoid Approaches (Retrosigmoid Transtentorial and Retrosigmoid Intradural Suprameatal Approaches) for Accessing the Petroclival Tumors. A Cadaveric Study

Abstract

Background The aim of our study was to compare the area of exposure at the ventral brainstem and petroclival region offered by the Kawase, retrosigmoid transtentorial (RTT), and the retrosigmoid intradural suprameatal (RISA) approaches in cadaveric models.

Methods We performed 15 approaches (five each of the Kawase, RISA, and RTT approaches) on silicone-injected adult cadaver heads. Ventral brainstem and petroclival areas of exposure were measured and compared.

Results The mean ventral brainstem area exposed by the Kawase approach was 55.00 ± 24.1 mm², significantly less than that exposed by RTT (441 ± 63.3 mm²) and RISA (311 ± 61 mm²) (p < 0.05). The area of ventral brainstem exposure was significantly more via RTT than through RISA (p = 0.01). The mean petroclival area of exposure through the Kawase approach was significantly smaller than that obtained through the RTT and RISA approaches (101.7 ± 545.01 mm², 696 ± 57.7 mm², and 716.7 ± 51.4 mm², respectively).

Conclusion Retrosigmoid approaches provide a greater exposure of the brainstem and petroclival areas. The Kawase approach is ideally suited for lesions around the Meckel cave with an extension into the middle fossa. These approaches can be used in conjunction with one another to access petroclival tumors.

Keywords

Kawase - retrosigmoid - transtentorial - suprameatal - petroclival tumors.

• References

• 1 Samii M, Carvalho GA, Tatagiba M, Matthies C. Surgical management of meningiomas originating in Meckel's cave. Neurosurgery 1997; 41 (4) 767-774 ; discussion 774–775
• 2 Samii M, Migliori MM, Tatagiba M, Babu R. Surgical treatment of trigeminal schwannomas. J Neurosurg 1995; 82 (5) 711-718
• 3 Samii M, Ammirati M. The combined supra-infratentorial pre-sigmoid sinus avenue to the petro-clival region. Surgical technique and clinical applications. Acta Neurochir (Wien) 1988; 95 (1–2) 6-12
• 4 Chanda A, Nanda A. Retrosigmoid intradural suprameatal approach: advantages and disadvantages from an anatomical perspective. Neurosurgery 2006; 59 (Suppl. 01) ):ONS 1-6
• 5 House WF, De la Cruz A, Hitselberger WE. Surgery of the skull base: transcochlear approach to the petrous apex and clivus. Otolaryngology 1978; 86 (5) ORL-770-ORL-779
• 6 Hsu FP, Anderson GJ, Dogan A , et al. Extended middle fossa approach: quantitative analysis of petroclival exposure and surgical freedom as a function of successive temporal bone removal by using frameless stereotaxy. J Neurosurg 2004; 100 (4) 695-699
• 7 Kawase T, Shiobara R, Toya S. Anterior transpetrosal-transtentorial approach for sphenopetroclival meningiomas: surgical method and results in 10 patients. Neurosurgery 1991; 28 (6) 869-875 ; discussion 875–876
• 8 Kawase T, Shiobara R, Toya S. Middle fossa transpetrosal-transtentorial approaches for petroclival meningiomas. Selective pyramid resection and radicality. Acta Neurochir (Wien) 1994; 129 (3–4) 113-120
• 9 Kawase T, Toya S, Shiobara R, Mine T. Transpetrosal approach for aneurysms of the lower basilar artery. J Neurosurg 1985; 63 (6) 857-861
• 10 Seoane E, Rhoton Jr AL. Suprameatal extension of the retrosigmoid approach: microsurgical anatomy. Neurosurgery 1999; 44 (3) 553-560
• 11 Spetzler RF, Daspit CP, Pappas CT. The combined supra- and infratentorial approach for lesions of the petrous and clival regions: experience with 46 cases. J Neurosurg 1992; 76 (4) 588-599
• 12 Spetzler RF, Hamilton MG, Daspit CP. Petroclival lesions. Clin Neurosurg 1994; 41: 62-82
• 13 Chang SW, Wu A, Gore P , et al. Quantitative comparison of Kawase's approach versus the retrosigmoid approach: implications for tumors involving both middle and posterior fossae. Neurosurgery 2009; 64 (3, Suppl): ons44-ons51; discussion ons51–ons52
• 14 Sekhar LN, Wright DC, Richardson R, Monacci W. Petroclival and foramen magnum meningiomas: surgical approaches and pitfalls. J Neurooncol 1996; 29 (3) 249-259
• 15 Park CK, Jung HW, Kim JE, Paek SH, Kim DG. The selection of the optimal therapeutic strategy for petroclival meningiomas. Surg Neurol 2006; 66 (2) 160-165 ; discussion 165–166
• 16 Natarajan SK, Sekhar LN, Schessel D, Morita A. Petroclival meningiomas: multimodality treatment and outcomes at long-term follow-up. Neurosurgery 2007; 60 (6) 965-979 ; discussion 979–981
• 17 Jung HW, Yoo H, Paek SH, Choi KS. Long-term outcome and growth rate of subtotally resected petroclival meningiomas: experience with 38 cases. Neurosurgery 2000; 46 (3) 567-574 ; discussion 574–575
• 18 Samii M, Tatagiba M, Carvalho GA. Retrosigmoid intradural suprameatal approach to Meckel's cave and the middle fossa: surgical technique and outcome. J Neurosurg 2000; 92 (2) 235-241
• 19 Watanabe T, Katayama Y, Fukushima T, Kawamata T. Lateral supracerebellar transtentorial approach for petroclival meningiomas: operative technique and outcome. J Neurosurg 2011; 115 (1) 49-54
• 20 Ambekar S, Amene C, Sonig A, Guthikonda B, Nanda A. Quantitative comparison of retrosigmoid intradural suprameatal approach and retrosigmoid transtentorial approach: implications for tumors in the petroclival region. J Neurol Surg B 2013; 74 (5) 300-304
• 21 Cantore G, Delfini R, Ciappetta P. Surgical treatment of petroclival meningiomas: experience with 16 cases. Surg Neurol 1994; 42 (2) 105-111
• 22 Erkmen K, Pravdenkova S, Al-Mefty O. Surgical management of petroclival meningiomas: factors determining the choice of approach. Neurosurg Focus 2005; 19 (2) E7
• 23 Behari S, Tyagi I, Banerji D , et al. Postauricular, transpetrous, presigmoid approach for extensive skull base tumors in the petroclival region: the successes and the travails. Acta Neurochir (Wien) 2010; 152 (10) 1633-1645
• 24 Drake CG. Surgical treatment of ruptured aneurysms of the basilar artery. Experience with 14 cases. J Neurosurg 1965; 23 (5) 457-473
• 25 Bochenek Z, Kukwa A. An extended approach through the middle cranial fossa to the internal auditory meatus and the cerebello-pontine angle. Acta Otolaryngol 1975; 80 (5–6) 410-414
• 26 Kawamata T, Katayama Y. Lateral supracerebellar transtentorial approach for petroclival lesions. [in Japanese]. No Shinkei Geka 2006; 34 (6) 567-575