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Quantitative Anatomical Comparison of Surgical Approaches to Meckel’s Cave

Background: Meckel’s cave is a challenging surgical target due to its deep location and proximity to vital neurovascular structures. Surgeons have developed various microsurgical transcranial approaches (MTAs) to access it, but there is no consensus on the best method. Newer endoscopic approaches ha...

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Autores principales: Zanin, Luca, Agosti, Edoardo, Ebner, Florian, de Maria, Lucio, Belotti, Francesco, Buffoli, Barbara, Rezzani, Rita, Hirt, Bernard, Ravanelli, Marco, Ius, Tamara, Zeppieri, Marco, Tatagiba, Marcos Soares, Fontanella, Marco Maria, Doglietto, Francesco
Formato: Online Artículo Texto
Lenguaje:English
Publicado: MDPI 2023
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10648058/
https://www.ncbi.nlm.nih.gov/pubmed/37959312
http://dx.doi.org/10.3390/jcm12216847
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author Zanin, Luca
Agosti, Edoardo
Ebner, Florian
de Maria, Lucio
Belotti, Francesco
Buffoli, Barbara
Rezzani, Rita
Hirt, Bernard
Ravanelli, Marco
Ius, Tamara
Zeppieri, Marco
Tatagiba, Marcos Soares
Fontanella, Marco Maria
Doglietto, Francesco
author_facet Zanin, Luca
Agosti, Edoardo
Ebner, Florian
de Maria, Lucio
Belotti, Francesco
Buffoli, Barbara
Rezzani, Rita
Hirt, Bernard
Ravanelli, Marco
Ius, Tamara
Zeppieri, Marco
Tatagiba, Marcos Soares
Fontanella, Marco Maria
Doglietto, Francesco
author_sort Zanin, Luca
collection PubMed
description Background: Meckel’s cave is a challenging surgical target due to its deep location and proximity to vital neurovascular structures. Surgeons have developed various microsurgical transcranial approaches (MTAs) to access it, but there is no consensus on the best method. Newer endoscopic approaches have also emerged. This study seeks to quantitatively compare these surgical approaches to Meckel’s cave, offering insights into surgical volumes and exposure areas. Methods: Fifteen surgical approaches were performed bilaterally in six specimens, including the pterional approach (PTA), fronto-temporal-orbito-zygomatic approach (FTOZA), subtemporal approach (STA), Kawase approach (KWA), retrosigmoid approach (RSA), retrosigmoid approach with suprameatal extension (RSAS), endoscopic endonasal transpterygoid approach (EETPA), inferolateral transorbital approach (ILTEA) and superior eyelid approach (SEYA). All the MTAs were performed both with 10 mm and 15 mm of brain retraction, to consider different percentages of surface exposure. A dedicated navigation system was used to quantify the surgical working volumes and exposure of different areas of Meckel’s cave (ApproachViewer, part of GTx-Eyes II, University Health Network, Toronto, Canada). Microsurgical transcranial approaches were quantified with two different degrees of brain retraction (10 mm and 15 mm). Statistical analysis was performed using a mixed linear model with bootstrap resampling. Results: The RSAS with 15 mm of retraction offered the maximum exposure of the trigeminal stem (TS). If compared to the KWA, the RSA exposed more of the TS (69% vs. 46%; p = 0.01). The EETPA and ILTEA exposed the Gasserian ganglion (GG) mainly in the anteromedial portion, but with a significant 20% gain in exposure provided by the EETPA compared to ILTEA (42% vs. 22%; p = 0.06). The STA with 15 mm of retraction offered the maximum exposure of the GG, with a significant gain in exposure compared to the STA with 10 mm of retraction (50% vs. 35%; p = 0.03). The medial part of the three trigeminal branches was mainly exposed by the EETPA, particularly for the ophthalmic (66%) and maxillary (83%) nerves. The EETPA offered the maximum exposure of the medial part of the mandibular nerve, with a significant gain in exposure compared to the ILTEA (42% vs. 11%; p = 0.01) and the SEY (42% vs. 2%; p = 0.01). The FTOZA offered the maximum exposure of the lateral part of the ophthalmic nerve, with a significant gain of 67% (p = 0.03) and 48% (p = 0.04) in exposure compared to the PTA and STA, respectively. The STA with 15 mm of retraction offered the maximum exposure of the lateral part of the maxillary nerve, with a significant gain in exposure compared to the STA with 10 mm of retraction (58% vs. 45%; p = 0.04). The STA with 15 mm of retraction provided a significant exposure gain of 23% for the lateral part of the mandibular nerve compared to FTOZA with 15 mm of retraction (p = 0.03). Conclusions: The endoscopic approaches, through the endonasal and transorbital routes, can provide adequate exposure of Meckel’s cave, especially for its more medial portions, bypassing the impediment of major neurovascular structures and significant brain retraction. As far as the most lateral portion of Meckel’s cave, MTA approaches still seem to be the gold standard in obtaining optimal exposure and adequate surgical volumes.
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spelling pubmed-106480582023-10-30 Quantitative Anatomical Comparison of Surgical Approaches to Meckel’s Cave Zanin, Luca Agosti, Edoardo Ebner, Florian de Maria, Lucio Belotti, Francesco Buffoli, Barbara Rezzani, Rita Hirt, Bernard Ravanelli, Marco Ius, Tamara Zeppieri, Marco Tatagiba, Marcos Soares Fontanella, Marco Maria Doglietto, Francesco J Clin Med Article Background: Meckel’s cave is a challenging surgical target due to its deep location and proximity to vital neurovascular structures. Surgeons have developed various microsurgical transcranial approaches (MTAs) to access it, but there is no consensus on the best method. Newer endoscopic approaches have also emerged. This study seeks to quantitatively compare these surgical approaches to Meckel’s cave, offering insights into surgical volumes and exposure areas. Methods: Fifteen surgical approaches were performed bilaterally in six specimens, including the pterional approach (PTA), fronto-temporal-orbito-zygomatic approach (FTOZA), subtemporal approach (STA), Kawase approach (KWA), retrosigmoid approach (RSA), retrosigmoid approach with suprameatal extension (RSAS), endoscopic endonasal transpterygoid approach (EETPA), inferolateral transorbital approach (ILTEA) and superior eyelid approach (SEYA). All the MTAs were performed both with 10 mm and 15 mm of brain retraction, to consider different percentages of surface exposure. A dedicated navigation system was used to quantify the surgical working volumes and exposure of different areas of Meckel’s cave (ApproachViewer, part of GTx-Eyes II, University Health Network, Toronto, Canada). Microsurgical transcranial approaches were quantified with two different degrees of brain retraction (10 mm and 15 mm). Statistical analysis was performed using a mixed linear model with bootstrap resampling. Results: The RSAS with 15 mm of retraction offered the maximum exposure of the trigeminal stem (TS). If compared to the KWA, the RSA exposed more of the TS (69% vs. 46%; p = 0.01). The EETPA and ILTEA exposed the Gasserian ganglion (GG) mainly in the anteromedial portion, but with a significant 20% gain in exposure provided by the EETPA compared to ILTEA (42% vs. 22%; p = 0.06). The STA with 15 mm of retraction offered the maximum exposure of the GG, with a significant gain in exposure compared to the STA with 10 mm of retraction (50% vs. 35%; p = 0.03). The medial part of the three trigeminal branches was mainly exposed by the EETPA, particularly for the ophthalmic (66%) and maxillary (83%) nerves. The EETPA offered the maximum exposure of the medial part of the mandibular nerve, with a significant gain in exposure compared to the ILTEA (42% vs. 11%; p = 0.01) and the SEY (42% vs. 2%; p = 0.01). The FTOZA offered the maximum exposure of the lateral part of the ophthalmic nerve, with a significant gain of 67% (p = 0.03) and 48% (p = 0.04) in exposure compared to the PTA and STA, respectively. The STA with 15 mm of retraction offered the maximum exposure of the lateral part of the maxillary nerve, with a significant gain in exposure compared to the STA with 10 mm of retraction (58% vs. 45%; p = 0.04). The STA with 15 mm of retraction provided a significant exposure gain of 23% for the lateral part of the mandibular nerve compared to FTOZA with 15 mm of retraction (p = 0.03). Conclusions: The endoscopic approaches, through the endonasal and transorbital routes, can provide adequate exposure of Meckel’s cave, especially for its more medial portions, bypassing the impediment of major neurovascular structures and significant brain retraction. As far as the most lateral portion of Meckel’s cave, MTA approaches still seem to be the gold standard in obtaining optimal exposure and adequate surgical volumes. MDPI 2023-10-30 /pmc/articles/PMC10648058/ /pubmed/37959312 http://dx.doi.org/10.3390/jcm12216847 Text en © 2023 by the authors. https://creativecommons.org/licenses/by/4.0/Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
spellingShingle Article
Zanin, Luca
Agosti, Edoardo
Ebner, Florian
de Maria, Lucio
Belotti, Francesco
Buffoli, Barbara
Rezzani, Rita
Hirt, Bernard
Ravanelli, Marco
Ius, Tamara
Zeppieri, Marco
Tatagiba, Marcos Soares
Fontanella, Marco Maria
Doglietto, Francesco
Quantitative Anatomical Comparison of Surgical Approaches to Meckel’s Cave
title Quantitative Anatomical Comparison of Surgical Approaches to Meckel’s Cave
title_full Quantitative Anatomical Comparison of Surgical Approaches to Meckel’s Cave
title_fullStr Quantitative Anatomical Comparison of Surgical Approaches to Meckel’s Cave
title_full_unstemmed Quantitative Anatomical Comparison of Surgical Approaches to Meckel’s Cave
title_short Quantitative Anatomical Comparison of Surgical Approaches to Meckel’s Cave
title_sort quantitative anatomical comparison of surgical approaches to meckel’s cave
topic Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10648058/
https://www.ncbi.nlm.nih.gov/pubmed/37959312
http://dx.doi.org/10.3390/jcm12216847
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