ResearchPad - skull-base:-operative-videos https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Retrosigmoid Approach for Trapping and Removal of a Distal Dissecting Superior Cerebellar Artery Aneurysm in a Child]]> https://www.researchpad.co/article/elastic_article_14387 Objectives  To demonstrate the feasibility of the retrosigmoid craniotomy for surgical management of vascular lesions located in the cerebellopontine angle (CPA).

Method  A previously healthy 2-year-old boy presented a sudden episode of torticollis to the left while sleeping. This episode was selflimited but it occurred two more times in a 6-day span. Torticollis worsened in the upright position, caused unsteady gait and refusal to walk from the child. The preoperative magnetic resonance imaging (MRI) showed the presence of a round, heterogenous vascular lesion in the left CPA. The lesion clearly enhanced after contrast administration. The preoperative angiography demonstrated the absence of left anterior inferior cerebellar artery anterior inferior cerebellar artery (AICA), being the left superior cerebellar artery (SCA) the supplier of the left lateral cerebellum. A blurred blush on the distal left SCA was compatible with a fusiform aneurysm. A standard retrosigmoid approach was planned for trapping and removal of the aneurysm.

Results  Through a left retrosigmoid craniotomy the aneurysm was approached, along with the different neurovascular structures of the CPA. The aneurysm leaned on the VII, VIII nerves complex and the superior petrosal vein, while tightly attached to the lateral cerebellum. Both proximal and distal SCA segments to the aneurysm were dissected, clipped, and divided for a complete trapping. Finally, the aneurysm was completely detached and removed in a whole piece. The patient fully recovered after surgery with no relapse of his symptoms.

Conclusion  The retrosigmoid craniotomy is a versatile approach that permits wide exposure of all CPA structures and adequate removal of distal aneurysms located in those cerebellar arteries supplying the lateral cerebellum.

The link to the video can be found at: https://youtu.be/oEVfy4goFYM .

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<![CDATA[Epidermoid Cyst in the Cerebellopontine Angle: Technical Description Video]]> https://www.researchpad.co/article/elastic_article_14386 Objectives  To describe the operative technique for treatment of epidermoid cysts in the cerebellopontine angle (CPA).

Design  The present video is a case report.

Setting  Patient is positioned in three-quarters prone. Retrosigmoid approach should be made under neurological monitoring and with neuronavegation to help achieve maximal safe resection. The skin incision is vertical, slightly curved, 5 mm medial to the mastoid notch. Craniectomy is superiorly limited by the transverse sinus and laterally limited by the sigmoid sinus. A C -shaped durotomy is made with its base protecting the sigmoid sinus. The lesion is removed in piecemeal fashion ( Fig. 1 ). The neurological monitoring helps.

Results  The patient was discharged 2 days later without neurological deficits.

Conclusions  The surgical treatment associated with neurological monitoring and neuronavegation is a safe procedure to treat epidermoid cysts in the CPA.

The link to the video can be found at: https://youtu.be/sEuFyq9c2sw .

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<![CDATA[Retrosigmoid Craniectomy for Resection of Epidermoid causing Trigeminal Neuralgia]]> https://www.researchpad.co/article/elastic_article_14385 The differential diagnosis for trigeminal neuralgia like-symptoms includes cerebellopontine angle lesions causing regional mass effect upon the trigeminal nerve ( Fig. 1 ). Here we present an operative video manuscript of a patient experiencing trigeminal neuralgia, secondary to an epidermoid cyst, in which a retrosigmoid craniectomy was performed to resect the epidermoid and decompress the trigeminal nerve ( Fig. 2 ). This video highlights the operative nuances to achieving a successful surgery, including appropriate patient positioning, dural exposure to the transverse-sigmoid sinus junction, arachnoid dissection, and decompression of cranial nerves. A gross total resection was achieved; the patient reported immediate relief of facial pain postoperatively and has been pain free at the ten month follow-up.

The link to the video can be found at: https://youtu.be/Ja2eE0uGk4E .

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<![CDATA[Retrosigmoid Intradural Suprameatal Approach for Petroclival Meningioma]]> https://www.researchpad.co/article/elastic_article_14384 Background  Anterior transpetrosal approach and the combined transpetrosal approach are the major surgical approaches for petroclival meningiomas. However, anterior petrosectomy is not preferable in cases with postoperative venous drainage disorder of the sylvian vein due to anatomical variations. Here we present a case of the successful removal of petroclival meningioma by the retrosigmoid intradural suprameatal approach (RISA).

Case Presentation  The patient was a 59-year-old woman with incidentally detected right petroclival meningioma. Although she had no neurological deficit, the tumor manifested with gradual growth on annual magnetic resonance imaging (MRI) during an 8-year follow-up. Three-dimensional computed tomography venography (3D–CTV) revealed sphenobasal type of the sylvian vein throughout the lateral side of the foramen ovale. Because the suprameatal tubercle was an obstacle to observe the Meckel's cave, RISA was selected for complete tumor excision. RISA could provide an excellent operative field around the Meckel's cave to confirm the remnant tumor. Postoperative MRI showed no evidence of the tumor, and the patient was discharged without any neurological deficit.

Conclusion  RISA can provide a favorable operative field for petroclival meningioma, particularly for cases with high risk of postoperative complications related to the sylvian vein.

The link to the video can be found at: https://youtu.be/cfci_zk0StU .

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<![CDATA[Middle Fossa Approach for Resection of an Intracanalicular Vestibular Schwannoma]]> https://www.researchpad.co/article/elastic_article_14383 Objective  This video was aimed to demonstrate the middle fossa approach for the resection of an intracanalicular vestibular schwannoma.

Design  Present study is a video case report.

Setting  The operative video is showing a microsurgical resection.

Participant  The patient was a 59-year-old man who presented with worsening headache and right-side hearing loss. He was found to have a right intracanalicular vestibular schwannoma. After weighing risks and benefits, he chose surgery to remove his tumor. Since his hearing remained “serviceable,” a middle fossa approach was chosen.

Main Outcome Measures  Pre- and postoperative patient photographs evaluated the muscles of facial expression as a marker for facial nerve preservation.

Results  A right middle fossa craniotomy was performed which allowed access to the floor of the middle cranial fossa. The greater superficial petrosal nerve (GSPN) and arcuate eminence were identified. Using these two landmarks, the internal acoustic canal (IAC) was localized. After drilling the petrous bone, the IAC was unroofed. The facial nerve was identified by stimulation and visual inspection and the tumor was separated from it with microsurgical dissection. In the end, the tumor was fully resected. Both the facial and cochlear nerves were preserved. Postoperatively, the patient experienced no facial palsy and his hearing is at baseline.

Conclusion  With radiosurgery gaining increasing popularity, patients with intracanalicular vestibular schwannomas are frequently treated with it, or are managed with observation. The middle fossa approach is therefore becoming a “lost art,” but as demonstrated in this video, remains an effective technique for tumor removal and nerve preservation.

The link to the video can be found at: https://youtu.be/MD6o3DF6jYg .

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<![CDATA[Microvascular Decompression for Geniculate Neuralgia through a Retrosigmoid Approach]]> https://www.researchpad.co/article/elastic_article_14382 Objectives  To describe a retrosigmoid approach for the microvascular sectioning of the nervus intermedius and decompression of the 5th and 9th cranial nerves, with emphasis on microsurgical anatomy and technique.

Design  A retrosigmoid craniectomy is performed in the lateral decubitus position. The dura is opened and cerebrospinal fluid (CSF) is released from the cisterna magna and cerebellopontine cistern. Dynamic retraction without rigid retractors is performed. Subarachnoid dissection of the cerebellopontine angle exposes the 7th to 8th nerve complex. A neuromonitoring probe is used with careful inspection of the microsurgical anatomy to identify the facial nerve and the nervus intermedius as they enter the internal auditory meatus. The nervus intermedius is severed. A large vein coursing superiorly across cranial 9th nerve was coagulated and cut. A Teflon pledget is inserted between a small vessel and the 5th nerve. Photographs of the region are borrowed from Dr. Rhoton's laboratory to illustrate the microsurgical anatomy.

Participants  The senior author performed the surgery. The video was edited by Drs. V.N. and J.B.

Outcome Measures  Outcome was assessed by postoperative neurological function.

Results  The nervus intermedius was successfully cut and the 5th and 9th nerves were decompressed. The patient's pain resolved after surgery and at later follow-up.

Conclusions  Understanding the microsurgical anatomy of the cerebellopontine angle is necessary to identify the cranial nerves involved in facial pain syndromes. Subarachnoid dissection and meticulous microsurgical techniques are key elements for a successful microvascular decompression.

The link to the video can be found at: https://youtu.be/pV5Wip7WusE .

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<![CDATA[Retrosigmoid Transmeatal Approach with 360-Degree Drilling of the Internal Auditory Canal for the Resection of Intracanalicular Meningioma]]> https://www.researchpad.co/article/elastic_article_14381 Introduction  Vestibular schwannomas are the most common lesions occupying the internal auditory canal (IAC); however, almost in 4 to 5% of meningiomas, metastases, cysts, lipomas, and cavernous malformations have been found in this location, mimicking schwannomas. Even though cerebellopontine angle (CPA) meningiomas with the involvement of the IAC are frequently encountered, the presence of a primary intracanalicular meningioma is rare.

Objective  To show the technical nuances of the retrosigmoid-transmeatal approach to successfully achieve gross total resection (GTR) with preservation of facial and auditory function.

Case Report  We present a left intracanalicular meningioma on a 60-year-old man with history of tinnitus and hearing loss. Magnetic resonance imaging (MRI) showed a left intracanalicular lesion completely obliterating the IAC and with minor extension to the CPA cistern, with the vestibulocochlear complex dislocated posteriorly, initially diagnosed as a Hannover's T2 vestibular schwannoma. The patient underwent a left retrosigmoid approach, and during the exposure of the lesion, the diagnosis of a meningioma became evident. The transmeatal phase of the approach was modified with a wide opening of the canal, including the anterior wall. Closure was performed using a muscle graft, duramater flap, and fibrin glue.

Results  GTR was achieved and the patient developed a mild facial palsy (House–Brackmann grade III) which completely recovered within 3 months.

Conclusions  The retrosigmoid transmeatal approach is suitable to achieve GTR in intracanalicular meningiomas. Some modifications of the approach intended for vestibular schwannomas are necessary and may be performed during the procedure.

The link to the video can be found at: https://youtu.be/A9OXRFIl1e8 .

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<![CDATA[CPA Epidermoid Cyst with Rare Anatomic Variant: Anterior Inferior Cerebellar Artery Embedded in the Subarcuate Fossa: Operative Video and Technical Nuances]]> https://www.researchpad.co/article/elastic_article_14380 Intracranial epidermoid cysts are considered benign tumors with a good general prognosis; however, their radical removal, including tumor capsule, is associated with significant morbidity, especially when the capsule is attached to neurovascular structures. We show an operative video describing main steps and surgical nuances in the resection of a large right cerebellopontine angle (CPA) epidermoid cyst in a 42-year-old male patient who presented with intractable trigeminal neuralgia. Craniectomy was performed to exposure the transverse-sigmoid sinus junction. A mold for a polymethylmethacrylate (PMMA) bone flap was built before opening the dura to avoid potentially neurotoxic effects on the cerebellum. The video illustrates the management of the rare anatomical variant of the anterior inferior cerebellar artery (AICA). Its loop was embedded in the dura, covering the subarcuate fossa where it gives off the subarcuate artery. Near total removal of the epidermoid cyst was achieved, leaving only a tiny capsule remnant adhering to the abducens nerve. Postoperatively the patient's trigeminal neuralgia was fully relieved and medications were discontinued. The patient's hearing was preserved per audiometry at the preoperative level (Gardner–Robertson II). Postoperative magnetic resonance imaging (MRI) revealed no signs of residual tumor. In this case, it was not possible to obtain optimal surgical exposure of the CPA without handling a rare anatomical anomaly of the AICA in the dura of the subarcuate fossa, which demanded coagulation and transection of the subarcuate artery and transposition of AICA with the dural cuff. This manipulation enabled optimal surgical removal of the epidermoid and didn't cause any neurological deficit.

The link to the video can be found at: https://youtu.be/lLZqBHlu-uA .

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<![CDATA[Endoscopic Resection of a Cerebellopontine Angle Meningioma via a Retrosigmoid Approach]]> https://www.researchpad.co/article/elastic_article_14379 A variety of lesions may arise within the cerebellopontine angle (CPA). Schwannomas and meningiomas are most commonly found in this location. Imaging characteristics of meningiomas include hyperdensity on head computed tomography (CT) and avid contrast enhancement on T1-weighted postcontrast magnetic resonance imaging (MRI). Here, we present the case of a 49-year-old woman with enlarging right CPA meningioma. The patient reported mild hearing loss on the right but her neurological exam was otherwise benign. Since the lesion was enlarging and symptomatic, the patient was offered resection of the mass for diagnosis and treatment via an endoscopic retrosigmoid approach. We provide a video that illustrates the steps taken to resect this mass endoscopically. After cerebrospinal fluid (CSF) was drained to achieve brain relaxation, the tumor was visualized. The tumor had a rich vascular supply and had the appearance of a typical meningioma. The bipolar was used to cauterize the tumor's vascular supply. The tumor capsule was then opened with the microscissors. The round knife, suction, and ultrasonic tissue debrider were used to debulk the tumor. After internal debulking of the tumor, the capsule was dissected off the cerebellum and mobilized. A combination of blunt and sharp dissection was done to free the tumor capsule from the adjacent structures. Inferiorly, the lower cranial nerves were visualized. Tissue pathology confirmed a diagnosis of grade I meningioma. A gross total resection was achieved and the patient remained neurologically stable, postoperatively. Furthermore, T1-weighted postcontrast brain MRI, 1 year after surgery, showed no residual.

The link to the video can be found at: https://youtu.be/X9c_inLp-So .

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<![CDATA[Lateral Basal Approach to CPA in Supine No-Retractor Method: Microvascular Decompression for Hemifacial Spasm]]> https://www.researchpad.co/article/elastic_article_14378 Objectives  In this video, we demonstrate our more basal approach in microvascular decompression for hemifacial spasm.

Design  The patient is in supine position with the head rotated maximally to the opposite side on the U -shaped head rest. The small cranial window is made at the lateral bottom of occipital cranium with the adequate superficial manipulation on the muscles layers in the craniocervical junction.

Results  The more basal approach enables the surgeon to access all the segments of the VIIth nerve tract without cerebellar retraction by spatula, especially in the case with vertebral artery associated compression.

Conclusion  This approach safely provides the ideal operative corridor promising sufficient decompression in micorvascular decompression for the VIIth nerve.

The link to the video can be found at: https://youtu.be/_nKSjGEHoB4 .

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<![CDATA[Endoscopic-Assisted Microvascular Decompression of Ectatic Vertebral Artery for Hemifacial Spasm: Operative Video and Technical Nuances]]> https://www.researchpad.co/article/elastic_article_14377 In this operative video atlas manuscript, the authors demonstrate the operative nuances and surgical technique for endoscopic-assisted microvascular decompression of a large ectatic vertebral artery causing hemifacial spasm. A retrosigmoid approach was performed and a large ectatic vertebral artery was transposed away from the root exit zone of cranial nerve VII ( Fig. 1 ). The lateral spread response disappeared, signifying adequate decompression of the facial nerve ( Fig. 2 ). The use of endoscopic-assistance during the microsurgical decompression was very useful to confirm the origin and also the resolution of neurovascular conflict. Postoperatively, the patient experienced immediate resolution of hemifacial spasm with normal facial nerve and hearing function. Written consent was obtained from the patient to publish videos, photographs, and images from the surgery.

The link to the video can be found at: https://youtu.be/RlMz44uCDCw .

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<![CDATA[Anterior Petrosal Approach for the Resection of a Petrous Apex Meningioma with Tentorial Infiltration]]> https://www.researchpad.co/article/elastic_article_14376 Objective  The anterior petrosal approach is an extension of the middle fossa approach, characterized by drilling of the posteromedial triangle of the middle fossa. Drilling the Kawase's rhomboid creates a surgical corridor to the posterior fossa after splitting the tentorium. We present a case of a petrous apex meningioma invading the tentorium and causing trigeminal neuralgia.

Results  The patient was positioned in a Mayfield with the head rotated. A frontotemporal incision was done. A basal craniotomy was done to allow epidural dissection. The anatomical landmarks were identified. The surgical video is analyzed together with cadaveric dissections to highlight landmarks when doing an anterior petrosectomy. The tentorium was identified and the infiltrated region was coagulated and removed. The tentorium was sharply sectioned until the free edge of the tentorium was opened. The tumor in the petrous apex was identified and removed. The trigeminal nerve was decompressed and a gross total resection was achieved with resolution of the symptoms.

Conclusion  The anterior petrosal approach is a useful corridor to remove tumors in the petrous apex that infiltrate the tentorium. A thorough knowledge of the anatomical landmarks is crucial to identify and delineate the limits of the Kawase's rhomboid. After evaluating different surgical corridors, the anterior petrosal approach allows a gross total resection including the removal of the infiltrated tentorium and a resolution of the symptoms.

The link to the video can be found at: https://youtu.be/p4KPUnM_bww .

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<![CDATA[Resection of Cerebellopontine Angle Meningioma via Retrosigmoid Approach Aiming for Hearing Improvement]]> https://www.researchpad.co/article/elastic_article_14375 We present a 71-year-old female case of left cerebellopontine angle (CPA) meningioma who presented with progressive hearing loss. The tumor was 35 mm in maximum diameter, obviously compressed the brain stem and cerebellum, and also displaced cranial nerves 7th and 8th anteriorly ( Fig. 1 ). Retrosigmoid approach was chosen to resect the tumor aiming for hearing improvement. We performed dissection of the tumor from cranial nerves 7th and 8th gently and resection of the tumor except for the part adhesive to these cranial nerves ( Fig. 2 ). Postoperative course was good without any new neurological deficit. Postoperative examination also showed improvement of high-frequency hearing of the left side, and auditory brainstem response demonstrated wave 2 to 5, which was not identify on preoperative examination. These procedures enabled safe and effective resection of the tumor and contributed to hearing improvement.

The link to the video can be found at: https://youtu.be/hkRSCxtV3bY .

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<![CDATA[Endoscopic Resection of a Cerebellopontine Angle Epidermoid Cyst via a Retrosigmoid Approach]]> https://www.researchpad.co/article/elastic_article_14373 A variety of lesions may arise within the cerebellopontine angle (CPA). Schwannomas and meningiomas are most commonly found in this location; however epidermoid cysts may also be found in this area. Here, we present the case of a 31-year-old man with severe right facial pain. Magnetic resonance imaging (MRI) demonstrated a right CPA mass that had heterogenous intensity on T2-weighted imagining and restricted diffusion on diffusion-weighted imaging. The patient was offered resection of the mass for treatment of his facial pain via an endoscopic retrosigmoid approach. We provide a video that illustrates the steps taken to resect this mass endoscopically. The mass was white and friable. The tumor was resected using a combination of sharp dissection with the microscissors and round knife and aspiration. As the tumor was removed, the 5th nerve was visualized deep to the tumor. The tumor was freed from any adhesions and was resected piecemeal. The round knife was used to free the tumor from surrounding venous structures. The brainstem and origin of the trigeminal nerve were visualized with further tumor debulking. We moved inferiorly to resect the remainder of the tumor. We worked around the surrounding vasculature to resect the tumor. Advancing the endoscope farther, we visualized Meckel's cave. The wound was irrigated and closed in standard fashion. Tissue pathology confirmed a diagnosis of epidermoid cyst. The vast majority of the mass was removed and the patient had resolution of his facial pain postoperatively.

The link to the video can be found at: https://youtu.be/fSw5sw8xQz0 .

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<![CDATA[Posterior Approach to Meckel's Cave: Retrosigmoid Craniectomy with Endoscopic Assistance]]> https://www.researchpad.co/article/elastic_article_14372 Background  Meckel's cave involvement in tumors pose a challenge due to their surrounding neurovascular structure and deep location.

Case Review  A 24-year-old male presented with progressive headaches and right sided trigeminal neuralgia with a large epidermoid. The tumor extended from the ambient cistern to the cerebellomedullary cistern and involved Meckel's cave ( Fig. 1 ).

Technical Note/Video Description  A retrosigmoid craniectomy was performed. Cranial nerves 3, 4, 6, 7, and 10, and auditory brainstem responses were monitored. Once the craniectomy was completed the dura was opened and cerebrospinal fluid (CSF) was released from the cisterna magna to allow for the tumor resection to be done without the use of any retractors ( Fig. 2 ). Care was taken to ensure that cranial nerves in the posterior fossa were detethered to prevent any traction injury. Using ring curettes the pearly white epidermoid tumor was able to be debulked. After all the possible tumor was resected with the microscope, the 30-degree endoscope was used to identify the porus trigeminus. Malleable ring curettes and a malleable suction were used to remove the soft tumor from this location. The patient transiently had loss of hearing but this returned within 2 weeks after surgery.

Conclusions  The retrosigmoid approach is familiar to all neurosurgeons and with the adjunct of an angled endoscope, the posterior Meckel's cave can be easily reached. This is particularly useful for tumors with soft consistency. The assistance of the endoscope allows Meckel's cave visualization without additional drilling while still allowing safe resection of tumor from around the trigeminal nerve.

The link to the video can be found at: https://youtu.be/01aqOyUmSW0 .

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<![CDATA[Microsurgical Resection of the Epidermoid Tumor in the Cerebellopontine Angle]]> https://www.researchpad.co/article/elastic_article_14371 In this video, we demonstrate epidermoid tumor microsurgical resection of the cerebellopontine angle (CPA) performed by the senior author (K.I.A.). Epidermoid tumors arise from ectoderm trapped within/displaced into the central nervous system. They show predilection for CPA Angle (up to 40%), 4th ventricle, suprasellar region, and spinal cord. 1 They are the 3rd most common CPA tumor, comprising approximately 7% of CPA pathology. CPA lesions can produce 5th and 7–12th cranial nerve neuropathies. 2 3 4 Recurrent episodes of aseptic meningitis caused by cyst content rupture may occur. Symptoms include fever, meningeal irritation, and hydrocephalus. A 26-year-old female presented with headaches. Head magnetic resonance imaging (MRI) revealed right CPA tumor with brain stem compression ( Fig. 1 , AC ). There was evidence of restricted diffusion in diffusion-weighted imaging, typical of epidermoid tumor. Surgery was performed in prone position with head turned 25 degrees to the ipsilateral side using retrosigmoid craniotomy. 5 Tumor was ventral to the 7th and 8th cranial nerve complexes, between the 5th nerve as well as toward the brainstem. The surgical plan was gross total resection with tumor capsule resection to prevent recurrence. 6 (Small residuals can be left behind when capsule is adherent to critical structures.) Tumor was adherent to brain stem perforators which were preserved using meticulous dissection. Cranial nerves and vascular structures were also left intact. We irrigated with antibiotic saline and used perioperative treatment to prevent aseptic meningitis. The pathohistological diagnosis revealed epidermoid tumor cyst. Postoperative MRI revealed complete resection ( Fig. 1 , DF ). The patient recovered fully and was neurologically intact.

The link to the video can be found at: https://youtu.be/LyWl-KZUSGY .

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<![CDATA[Retrosigmoid Craniotomy for Cerebellopontine Epidermoid Cyst]]> https://www.researchpad.co/article/elastic_article_14370 Epidermoid cysts are benign lesions. The goal of this surgery is complete removal while preserving cranial nerves. Here, we illustrate the case of a 31-year-old male who presented with persistent headache following a short period of impaired consciousness. Imaging revealed a mass at the cerebellopontine angle (CPA) which at surgery proved to be an epidermoid cyst. In this video, we present the key steps of surgery. The postoperative course was uneventful and the patient was symptom-free at the 3 months of follow-up.

The link to the video can be found at: https://youtu.be/0xwpkKwQoLI .

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<![CDATA[Surgical Clipping of a Petrosal Tentorial Dural Arteriovenous Fistula (Lawton's Type 5)]]> https://www.researchpad.co/article/elastic_article_14369 Objectives  To demonstrate the surgical clipping of a lateral petrosal tentorial dural arteriovenous fistula (DAVF), located in the cerebellopontine angle (CPA), through a retrosigmoid approach.

Method  A previously healthy 49-year-old man presented a sudden episode of headache, photophobia, and dizziness. Due to the persistence of his symptoms despite proper analgesic treatment, he sought medical attention. The initial computed tomography (CT) scan showed a hyperdense lesion in the left CPA. Magnetic resonance imaging (MRI) demonstrated the vascular nature of the lesion, corresponding to an engorged superior petrosal vein (SPV) and Rosenthal's vein. The preoperative angiography showed a lateral tentorial DAVF (Lawton's type 5), fed by multiple transpetrous branches coming off the external carotid artery, and draining into the SPV. A standard retrosigmoid approach was planned for clipping and exclusion of the DAVF.

Results  Through a left retrosigmoid craniotomy the DAVF was approached, along with the different neurovascular structures of the CPA. The DAVF originated at the tentorial petrosal junction. The fistulous vein was closely attached to the trigeminal nerve and the anterior inferior cerebellar artery (AICA). The fistulous vein was dissected and clipped close to its base at the lateral tentorium, achieving complete occlusion of the DAVF. The patient fully recovered after surgery with neither relapse of his symptoms nor postoperative complications.

Conclusion  The retrosigmoid craniotomy is the best surgical approach for lateral tentorial DAVFs, as it provides a direct way to the fistula origin and permits a successful clipping of the draining vein.

The link to the video can be found at: https://youtu.be/Fj3uqrTPX5c .

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<![CDATA[Microvascular Decompression and Nervus Intermedius Sectioning for the Treatment of Geniculate Neuralgia]]> https://www.researchpad.co/article/elastic_article_14368 Objectives  Demonstrate the surgical treatment of geniculate neuralgia via microvascular decompression and nervus intermedius sectioning.

Designs  Single case-based operative video.

Setting  Tertiary center with dedicated skull base team.

Participants  The patient is a 62-year-old female with a history of deep right-sided otalgia consistent with geniculate neuralgia. She failed appropriate medical treatment. Her magnetic resonance imaging (MRI) showed an ectatic vertebrobasilar system as well as an anterior inferior cerebellar artery (AICA) loop causing compression of the VII/VIII nerve complex in the cerebellopontine angle.

Main Outcome Measures  Resolution of right-sided otalgia.

Results  The patient underwent retrosigmoid craniotomy with microvascular decompression of the VII/VIII nerve complex and nervus intermedius sectioning. Intraoperatively, the patient was noted to have an ectatic vertebral artery and AICA that were compressing the root entry zone of the VII/VIII nerve complex. Microvascular decompression was performed of both the vertebral artery and AICA with Teflon. The nervus intermedius was sharply sectioned. The patient's postoperative course was uneventful with no complications. She continues to have resolution of her right sided otalgia at 6 months postoperatively.

The link to the video can be found at: https://youtu.be/uRb_QfrINSk .

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<![CDATA[Staged Approach for Petroclival Meningioma Resection]]> https://www.researchpad.co/article/elastic_article_14367 Introduction  Petroclival meningiomas represent very uncommon and challenging tumors. Surgical morbidity is high due to the difficult and complex approaches to this area. In the present video presentation, we demonstrate a staged-approach surgical resection for petroclival meningioma.

Patient and Methods  A 47-year- old female was incidentally diagnosed with right sizable petroclival meningioma ( Fig. 1 ). The decision to proceed with a staged approach was made based on size and extension of the tumor to both the middle and posterior fossa. At the first stage we performed a right anterior petrosectomy with the patient in the supine position and the head turned 45 degrees to the left. Residual tumor was left behind along its inferior pole. At the second stage, 2 weeks after the 1st surgery, a right retrosigmoid craniotomy was performed with the patient placed on left park-bench position and the residual tumor was removed. The patient tolerated both stages very well without significant neurological deficits except a transient diplopia after the first stge. Postoperative magnetic resonance imaging (MRI) revealed gross total resection of the tumor.

Conclusion  Staged approach for petroclival meningiomas represents a safe and effective surgical management, tolerable for the patient and more comfortable for the neurosurgeon.

The link to the video can be found at: https://youtu.be/QJJchjAwD5c .

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