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Print date: 13.6.2017 11:2917.5.2019 9:7

Richard Kerr, Reuben D Johnson

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Introduction and Background | Operative Detail and Preparation | Outcomes and Postoperative Course | References

Introduction and Background

Alternative Procedures

Translabyrinthine approach, middle fossa approach

Stereotactic radiosurgery

Goals

To allow surgical access to lesions located in the cerebellopontine angle (CPA)

Advantages

Allows access to the CPA with good visualization of the lower cranial nerves (CNs)

Hearing preservation is possible with this approach.

Avoids the risk of temporal lobe contusion and injury to the vein of Labbé

Indications

Vestibular schwannomas: Large tumors causing brainstem compression; medium-size tumors with worsening of
symptoms (progressive hearing loss or ataxia) or with rapid change in size on serial imaging; patient choice for
small tumors

CPA meningiomas

Epidermoid cysts

Contraindications

Coincident supratentorial mass lesion or hydrocephalus (The supratentorial lesion may need to be resected first
and shunting should be considered for symptomatic hydrocephalus in the first instance.)

Advanced age or extensive medical history

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Asymptomatic tumors too small to warrant surgical resection

Operative Detail and Preparation

Preoperative Planning and Special Equipment

Positioning in the park-bench lateral position with the head held in a Mayfield clamp forward-flexed 30 degrees,
laterally flexed 30 degrees, and rotated 30 degrees

Intraoperative electromyography to monitor function of CN VII (and CN IX for large tumors). Brainstem
auditory evoked potentials can be used to monitor CN VIII. Other modalities may include somatosensory
evoked potentials, trigeminal, and vagal monitoring.

Neurooperative microscope, ultrasonic aspirator, fine-tip bipolar electrocautery, and self-retaining retractors are
needed.

Preoperative steroids and antibiotics

Preoperative laboratory studies

Neuronavigation can also be helpful in delineating important anatomic landmarks.

Consideration for lumbar drain, which can help facilitate exposure

Consideration for preparing the abdominal wall in case a fat graft needs to be harvested, which can help close
defects within the petrous bone after drilling

Expert Suggestions / Comments

This procedure should be performed by posterior skull-base neurosurgeons.

An otolaryngologist trained in this approach or a skull-base surgeon may be involved in the procedure to help
access lesions in the internal auditory canal and assist in drilling of the petrous temporal bone.

Good communication between the anesthesiologist and the neurophysiologist throughout the procedure is
paramount.

Key Steps of the Procedure

It is essential to have an understanding of the location of the transverse and sigmoid sinuses using external
landmarks. In general, a line from the external auditory canal to the inion will define the transverse sinus.
Neuronavigation can also be helpful in delineating these landmarks. A small depression in the skull in this region, the
digastric groove, can be used to locate the junction of the transverse and sigmoid sinuses. With these landmarks
identified, a vertical linear incision of 8–10 cm is made 1–2 cm behind the mastoid eminence with the midpoint of the
incision centered on the eminence. Layers are incised down to bone and retracted medially and laterally. Deep cervical
fascia can be taken for dural repair, or the incision may be extended superiorly to obtain at least a 4-cm diameter
pericranial graft.

A craniotomy is performed to allow visualization of the posterior surface of the petrous bone. To avoid bleeding from
the sigmoid sinus or an emissary vein the initial burr hole is located medially and posterior to the body of the mastoid.
The craniotomy is extended to expose the edges of the sigmoid and transverse sinuses (Fig. 43.1). Mastoid air cells
may be encountered laterally and should be sealed immediately with bone wax. The dura can either be opened in a
C-shape with its base located medially, or it can be opened in a stellate fashion allowing for flaps of dura that can be
retracted with sutures.

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Fig. 43.1 Artist's rendering of a patient in park-bench position with head turned “30, 30, 30” in Mayfield. Inset shows
retrosigmoid area to demonstrate location of linear incision and burr hole for planned craniotomy. 1. Craniotomy outline; 2.
skin incision; 3. transverse sinus; 4. asterion; 5. sigmoid sinus. EAC, external auditory canal.

The petrosal surface of the cerebellum is then gently retracted and arachnoid opened inferiorly so that cerebrospinal
fluid (CSF) can drain out to facilitate exposure of the CPA. Care should be taken not to tear bridging veins between
the cerebellum and petrous bone. The superior petrosal vein (Dandy vein) may be encountered and can be coagulated
and divided to facilitate exposure if required. Depending on the size of the lesion, the CNs will come into view in the
cerebellopontine cistern with CNs IX, X, and XI forming a group most inferiorly. CN VII is located ~3 mm above IX
and is deep to CN VIII passing with it into the internal auditory canal (IAC). The position of CN VII may be confirmed
using stimulation. The choroid plexus acts as a good landmark for the origin of the facial nerve. The anterior inferior
cerebellar artery (AICA) is the most prominent artery usually located inferior to CNs VII and VIII and often gives off a

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branch that passes between these two nerves. CN V is most superior with the superior cerebellar artery (SCA) in close
association (Fig. 43.2).

Fig. 43.2 (A) Artist's rendering showing landmarks to locate transverse and sigmoid sinuses and exposure given by the
craniotomy, as well as dural incision. (B) Exposure of the cerebellopontine angle neurovascular structures; a small
meningioma is seen abutting on the cranial nerve VII/VIII complex. DI, dural incision; T, tumor adherent to dura; BA, basilar
artery; FL, flocculus; CN, cranial nerve; PICA, posterior inferior cerebellar artery; AICA, anterior inferior cerebellar artery;
SCA, superior cerebellar artery; TS, transverse sinus; SS, sigmoid sinus.

The most common tumors of the CPA are vestibular schwannomas (85%), followed by meningiomas (10%) and
epidermoids (5%). Details of resection of vestibular schwannoma and epidermoids are discussed in other chapters. As
such, a brief discussion of the details of resection of CPA meningioma follows. The CPA is the most common location of
meningiomas within the posterior fossa. These tumors are more likely to present with facial numbness when

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compared with vestibular schwannomas, which typically present with hearing loss. Unlike the infiltrative nature of
epidermoids or the origin of schwannomas from CNs, meningiomas typically displace CNs and a clear plane between
the nerve and the tumor can be defined and dissected. The CNs are typically identified by electrophysiologic
monitoring such as brainstem auditory evoked responses and facial nerve stimulation, along the surface of the tumor.
Typically cottonoid patties can then be placed between the tumor and the CN to protect the brainstem and define
important planes. Once a surface devoid of CN is identified, the capsule of the tumor is then opened at that location
with microscissors and bipolar cautery. The tumor is then carefully debulked using the ultrasonic aspirator as well as
suction and irrigation. The tumor's vascular supply originates from vessels traversing the tentorium and going through
the petrous temporal bone. These vessels are commonly encountered later in the dissection and debulking. As such, it
is very important to keep in mind the location of the CN VII and VIII complex and avoid coagulation near these
structures. As the tumor is debulked, it is then folded upon itself creating a space between the tumor and the CN and
facilitating removal of the capsule. Once the tumor has been removed from the CPA and CNs isolated, attention can
then be directed to the IAC portion of the tumor. To expose tumor extending into the IAC the dural lining over this
opening is coagulated and incised. A diamond drill is then used to expose the IAC taking great care to minimize bone
dust by the use of constant irrigation. The preoperative computed tomography (CT) scan is carefully studied to assess
for extent of IAC involvement (generally < 1 cm) as well as hyperostosis. The surrounding dura that is likely to be
invaded by tumor should also be removed and the involved bone drilled. If it is not possible to remove surrounding
dura due to safety issues, the edges of the dura are coagulated, hence achieving a Simpson grade 2 resection.

Once the tumor is resected the wound must be meticulously inspected for hemostasis. Areas of bone around the IAC
and mastoid are carefully waxed to occlude any air cells. Harvested pericranium is used as a dural graft, with great
care to ensure a watertight seal. The dural repair can be further secured using dural glue. Harvested abdominal fat
may be used to pack the mastoid air cells if these are opened during drilling. The bone flap is replaced without need
to secure it in place. The wound is closed in watertight sutured layers.

Avoidances / Hazards / Risks

Care should be taken to avoid excessive retraction of the cerebellum. Opening the cisterna magna and draining
CSF as well as using a lumbar drain can help in relaxing the cerebellum and improvement of the exposure.

The use of diuretics may also provide more access.

Manipulation of CNs during tumor dissection should be minimized as much as possible.

Salvage and Rescue

If a venous sinus is entered, direct pressure should be applied with Surgicel™ (Johnson & Johnson Inc., New
Brunswick, NJ) and patties until the bleeding stops. The sinus can then be primarily repaired by using suture or
hemoclips. Alternatively, fibrin glue (Tisseel™, Baxter, Deerfield, IL) and absorbable gelatin sponge (Gelfoam™,
Pfizer Inc., New York, NY) can be used to help achieve hemostasis.

If a semicircular canal or mastoid air cell is entered, it should be packed off with bone wax immediately to avoid
postoperative CSF leakage and reduce infection risk.

Outcomes and Postoperative Course

Postoperative Considerations

The patient is monitored in a high-dependency unit for the first 24 hours postoperatively.

A CT scan should be obtained postoperatively to assess for hydrocephalus or posterior fossa hematoma.

The patient's vital signs are closely monitored, including brainstem reflexes. Swallowing and speech are
assessed once the patient is extubated.

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The patient is kept on postoperative steroids, which are tapered. Antibiotics may be given if a lumbar drain was
left in place.

In the event where a near total or subtotal resection was performed, the patient will need to obtain serial
magnetic resonance images (MRIs) on a 6-month or yearly basis to assess progress of the residual. Adjuvant
therapy such as stereotactic radiosurgery may be necessary in these cases, depending on the pathology and
especially in cases of higher-grade tumors.

Complications

Major complications include subdural hematoma formation, brainstem infarction (arterial, venous, or sinus
occlusion), and CSF leak.

CSF leak can present through the wound, as rhinorrhea, or as a salty taste in the back of the throat. A CSF leak
should be dealt with by reexploration and/or placement of a lumbar drain.

Facial nerve palsies may occur without section of the facial nerve and may be delayed. Such palsies usually
respond to a short course of steroid treatment.

Hydrocephalus may also develop postoperatively due to brainstem or cerebellar edema, or may be
communicating. Careful observation must be employed with a low threshold for CT scanning to look for
ventricular dilatation.

Venous sinus injury: Injury to the transverse and sigmoid sinuses, venous bleeding from an emissary vein or
the petrous vein

Other complications can include cerebellar contusion, trigeminal nerve palsy, hearing loss, lower CN paralysis,
entrance of semicircular canals, and bleeding from the anterior inferior cerebellar artery (AICA).

References

1 Lang JJr, Samii A. Retrosigmoidal approach to the posterior cranial fossa. An anatomical study. Acta Neurochir

(Wien). 1991;111(3-4):147-153.

2 Ojemann RG. Microsurgical suboccipital approach to cerebellopontine angle tumors. Clin Neurosurg.

1978;25:461-479.

3 Ojemann RG. Retrosigmoid approach to acoustic neuroma (vestibular schwannoma). Neurosurgery.

2001;48(3):553-558.

4 Rhoton ALJr. Meningiomas of the cerebellopontine angle and foramen magnum. Neurosurg Clin N Am.

1994;5(2):349-377.

5 Yasargil MG, Smith RD, Gasser JC. The microsurgical approach to acoustic neuromas. Adv Tech Stand
Neurosurg. 1977;4:93-128.

6 Rock JP, Ryu S, Anton T. Posterior fossa meningiomas. In: Schmideck HH, Sweet WH, eds. Operative
Neurosurgical Techniques. Philadelphia, PA:WB Saunders;2005:975–991

Source:

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Cerebellopontine Angle Tumors

From: Michael L. Levy, Scott C. Berta, Remi Nader, Abdulrahman J. Sabbagh, Cristian Gragnanielllo: Neurosurgery
Tricks of the Trade. Cranial. (2013; 1st Edition)

Download bibliographical data (RIS)

Short link: https://medone-neurosurgery.thieme.com/32CZ6

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