Now in a fully revised and expanded second edition, this book remains the gold standard guide to the surgical treatment of diseases in the cerebellopontine angle (CPA), the fragile area of the skull base that Harvey Cushing famously described as “the bloody angle.” This edition combines current information on the relevant clinical diseases of the CPA with dramatically improved surgical management of its diseases, arranged in five thematic sections.
The first section presents the basis and rationale for treatment, including historical perspectives, microsurgical anatomy, relevant radiology and neurology. Part two is composed of chapters on surgical approaches, and parts three and four provide detailed descriptions of surgical management techniques for vestibular schwannomas and non schwannomatous lesions, respectively. The final section provides 21 distinct clinical cases with associated video segments, demonstrating the approaches and techniques in real time.
With images courtesy of the renowned Barrow Neurological Institute, Surgery of the Cerebellopontine Angle, Second Edition is a boon resource for expert specialists in neurosurgery, neurotology, neuroradiology, otolaryngology/head and neck surgery, and endovascular surgery.
Author(s): Nicholas C. Bambakidis, Cliff A. Megerian, Robert F. Spetzler
Edition: 2
Publisher: Springer
Year: 2023
Language: English
Pages: 407
City: Cham
Preface
Contents
Contributors
Part I: Foundations for Treatment
1: Historical Perspectives
History of Vestibular Schwannoma Surgery
Otology and the Operating Microscope
Modern Surgery in the Cerebellopontine Angle
Neurovascular Decompression
Radiosurgery
Conclusions
References
2: Microsurgical Anatomy of the Cerebellopontine Angle and Its Suboccipital Retromastoid Approaches
Relationships Between the Cranial Surface and the CPA
Osseous and Muscular Relationships, Transverse and Sigmoid Sinuses, and External Surgical Landmarks
Relationships Among CPA Nerves and Brainstem
CPA Upper Neurovascular Complex
Middle Neurovascular Complex of the CPA
Lower Neurovascular Complex of the CPA
Summary
References
3: Radiology
Technical Considerations
Screening Studies
General Classification of Lesions
Extraaxial Lesions
Vascular Lesions
Extradural Lesions
Intraaxial Lesions
Angiography
Preoperative and Follow-Up Imaging
Preoperative Imaging of Vestibular Schwannomas
Follow-Up Assessment After Treatment of Vestibular Schwannomas
Imaging Pitfalls and Pseudomasses
References
4: Neurology
Anatomy
Etiologies
Clinical Manifestations
Neurological Examination of the CPA
Additional Testing
Brainstem Syndromes
References
Part II: Surgical Approaches
5: Approaches to the Cerebellopontine Angle
Introduction
Retrosigmoid Approach
Surgical Technique
Transpetrosal Approaches
Retrolabyrinthine Approach
Translabyrinthine Approach
Transcochlear Approach
Middle Fossa Approach
Surgical Technique
Extended Middle Fossa Approach
Endoscopic Approach
Neuromonitoring and Anesthetic Considerations
Facial Nerve Monitoring
Vestibulocochlear Nerve Monitoring
Glossopharyngeal and Vagus Nerve Monitoring
Summary
References
6: Combined Surgical Approaches
General Considerations
Transpetrosal Approaches
Combined Open Approaches
Endoscopic Endonasal Approach to the Petroclival Region
Endoscopic Endonasal Approach Considerations
Surgical Decision-Making
References
7: Functional Surgery of the Cerebellopontine Angle
Vestibular Neurectomy
Clinical Material and Methods
Operative Technique for Vestibular Neurectomy
Outcomes of Vestibular Neurectomy
Advantages and Disadvantages of Different Approaches for Vestibular Neurectomy
Neurectomy of the Nervus Intermedius
Case Report
Diagnosis of Geniculate Neuralgia
Functional Anatomy
Neurectomy of the Glossopharyngeal Nerve
Natural History and Clinical Manifestations of Glossopharyngeal Neuralgia
Functional Anatomy
Differential Diagnosis
Treatment Options
Preoperative Preparation
Patient Positioning
Operative Technique
Microvascular Decompression
Case Report: Microvascular Decompression for Tinnitus
Authors’ Experience: Microvascular Decompression for Trigeminal Neuralgia or Hemifacial Spasm
Endoscopy as a Surgical Adjunct During Microvascular Decompression
Auditory Brainstem Implantation
Translabyrinthine Approach
Retrosigmoid Approach
Authors’ Clinical Experience
Highlights of Auditory Brainstem Implantation
Summary and Conclusions
References
8: Endoscopy in the Cerebellopontine Angle
Equipment
Overview of Endoscopic Techniques
Operative Technique
Avoiding Complications with the Endoscope
Specific Applications of the Endoscope in the CPA: Cranial Nerve Decompression
Trigeminal Neuralgia
Hemifacial Spasm
Glossopharyngeal Neuralgia
Specific Applications of the Endoscope in the CPA: CPA Masses
Vestibular Schwannoma
Meningioma
Epidermoid
Arachnoid Cysts
Conclusion
References
Part III: Vestibular Schwannomas
9: Biology and Genetics of Vestibular Schwannomas in Tumors of the Cerebellopontine Angle
Background
The NF2 Gene
Structure and Function of the NF2 Protein, Merlin
NF2 Mutations and Their Clinical Correlation
Merlin Acts as a Tumor Suppressor
Molecular Roles of the Merlin Tumor Suppressor and Consequence of Its Loss in Vestibular Schwannomas
Merlin and CD44-Mediated Contact Inhibition of Cellular Proliferation
Merlin-Rac1 Mediated Cytoskeletal Interactions
Merlin Activates the Mammalian Hippo Pathway to Induce Growth Arrest
Merlin Inhibits the Mammalian Target of Rapamycin Pathway
Additional Merlin-Mediated Pathways
Epigenetic Alterations in Vestibular Schwannomas
Histone Modifications and the Role of Histone Deacetylase Inhibitors
Vascular Endothelial Growth Factor in VS
Bench to Bedside: Molecular Targets of VS Therapy
Summary
References
10: Treatment Options for Acoustic Neuroma, Including Stereotactic Radiosurgery
Introduction
Observation
Stereotactic Radiation and Radiosurgery
Stereotactic Radiosurgery
Tumor Control Rates
Hearing Preservation
Cranial Nerve Function
Fractionated Radiotherapy
Comparing Radiosurgery and Radiotherapy
Proton Beam Therapy
Risk of Secondary Malignancy
Summary
Microsurgery
Hearing Results
Facial Nerve Outcomes
Cerebrospinal Fluid Leakage
Patient Reported Quality of Life
Conclusions
References
11: Translabyrinthine Approach
Preoperative Evaluation
Patient Selection
Surgical Procedure
Tumor Dissection
Complications
Outcomes
Postoperative Care
Conclusions
References
12: Hearing Rehabilitation Following Acoustic Neuroma Surgery
Unilateral Hearing Loss
Hearing Rehabilitation
Contralateral Routing of Signal
Osseointegrated Hearing Implants
Auditory Brainstem Implants
Cochlear Implantation
References
13: Acoustic Neuroma Surgery: Retrosigmoid Techniques
Pathology and Pathophysiology
Investigation
Audiometry
Classification
Definition of Success
Auditory Brainstem Responses
Otoacoustic Emissions
Vestibular Testing
Radiology
MRI Screening: When to Do It?
Imaging Characteristics
Complications
Operative Techniques
Retrosigmoid Approach
Patient Position and Monitoring
Incision
Soft Tissue Dissection
Craniotomy
Dural Opening
Retraction
Identification of Nerves at Brainstem
Removal of CPA Tumor
Opening the Posterior Wall of the IAC
Removal of Intracanalicular Tumor
Closure
Microsurgical Dissection
Intraoperative Monitoring
Hearing Results
Which Approach?
Follow-Up and Long-Term Outcomes
Imaging
Hearing
Long-Term Risk of Recurrence
References
14: Acoustic Neuroma Surgery: Middle Fossa Approach
Introduction
Surgical Candidacy
Surgical Technique
Preoperative Preparation
Surgical Technique
Postoperative Care
Complications and Outcomes
Conclusion
References
15: Complications and Cranial Nerve Rehabilitation
Cerebrospinal Fluid Leak and Meningitis
Vascular Complications
Venous Sinus Thrombosis
Cranial Nerve Dysfunction
Vestibular Dysfunction
Facial Nerve
Delayed Facial Paralysis
Facial Paralysis and Eye Complications
Lower Cranial Nerves
Headache
Conclusion
References
16: Facial Reanimation
Anatomy of Facial Nerve
Nerve Injury Classification
First-Degree Injury
Second-Degree Injury
Third-Degree Injury
Fourth-Degree Injury
Fifth-Degree Injury
Nerve Repair and Nerve Grafting
Nerve Grafting
Facial Reanimation
Nerve Substitution Techniques
Hypoglossal–Facial Transfer (Cranial Nerve XII–VII Crossover)
Surgical Technique
Trigeminal-to-Facial Nerve Transfer
Surgical Technique
Cranial Nerve VII–VII Cross-Facial Grafting
Surgical Technique
Regional Muscle Transfer Techniques
Temporalis Muscle Transfer
Surgical Technique
Other Regional Muscle Transfers
Free-Muscle Transfer
Surgical Technique
Static and Adjunctive Facial Reanimation
Summary
References
17: Hearing and Surgical Considerations in Neurofibromatosis Type 2
Diagnosis
Genetics
Vestibular Schwannomas
Schwannomas Involving Other Cranial Nerves
Meningiomas
Collision Tumors
Ependymomas
Ocular Findings
Surgical Management of Vestibular Schwannomas and Hearing Rehabilitation in NF2
Observation Without Surgical Intervention
Middle Fossa Craniotomy with Decompression of the IAC
Hearing Preservation Surgery with Total Tumor Removal
Retrosigmoid Craniotomy with Partial Tumor Removal
Nonhearing Preservation Surgery with Total Tumor Removal
Hearing Rehabilitation Via an ABI or CI
Radiation Therapy for NF2
Surgical Management of Other Tumors in NF2
Medical Management of NF2
Conclusion
References
18: Prevention and Management of CSF Leakage Postoperatively
Introduction
Overall Rates
Preoperative Issues
Translabyrinthine Approach
Retrosigmoid Approaches
Middle Fossa Approach
Other Approaches
Management Options
Recalcitrant Cases
Conclusion
References
Part IV: Nonschwannomatous Lesions of the CPA
19: Temporal Bone Neoplasms
Differential Diagnosis
Temporal Bone Paragangliomas
Pathology
Clinical Manifestations
Classification Schemes
Operative Management
Radiotherapy
Endolymphatic Sac Tumors
Pathology
ELST and VHL
Clinical Manifestations
Diagnosis
Treatment
Hemangiomas of the Geniculate Ganglion and Internal Auditory Canal
Carcinomas of the Temporal Bone
Soft Tissue Sarcomas
Rhabdomyosarcomas
Diagnosis
Treatment
Hematologic Malignancies
Metastasis of the Temporal Bone
Cholesterol Granulomas
Conclusion
References
20: Congenital Rest Lesions and Rare Tumors
General Principles of the Lateral Suboccipital Retrosigmoid Approach
Anatomical Considerations
General Techniques of Surgical Resection
Epidermoids and Dermoids
Arachnoid Cysts
Nonvestibular Schwannomas
Metastatic and Exophytic Lesions
Lipomas
Conclusions
References
21: Vascular Lesions of the Cerebellopontine Angle
Vascular Loop Compression
Aneurysms
Fusiform Aneurysms
Saccular Aneurysms
Treatment of Aneurysms
Choice of Surgical Approach
Endovascular Options for Aneurysms
Arteriovenous Malformations
Cavernous Malformations
Hemangioblastomas
Other Hypervascular Lesions
Conclusion
References
Part V: Cases and Approaches (Animations and Videos)
22: Case 1: Retrosigmoid Approach for Vestibular Schwannoma
Summary
Case Presentation
Approach
Alternatives
Positioning
Incision
Operation
Post-op
Outcome
Pearls and Pitfalls
Discussion
Reference
23: Case 2: Combined Transpetrosal Approach with Hearing Preservation for Resection of a Meningioma
Summary
Case Presentation
Approach
Alternatives
Anatomy
Positioning
Incision
Operation
Post-op
Outcome
Pearls and Pitfalls
Discussion
Reference
24: Case 3: Far-Lateral Approach for a Foramen Magnum Meningioma
Summary
Case Presentation
Approach
Alternatives
Positioning
Incision
Operation
Post-op
Outcome
Pearls and Pitfalls
Discussion
25: Case 4: Resection of an Acoustic Schwannoma Complicated by Tumor Encasement of the Anterior Inferior Cerebellar Artery Using a Translabyrinthine Approach
Case Presentation
Approach
Alternatives
Surgery
Outcome
26: Case 5: Transcondylar Approach for Giant Aneurysm with Posterior Inferior Cerebellar Artery Bypass
Summary
Case Presentation
Approach
Alternatives
Positioning
Incision
Surgery
Post-op
Outcomes
Pearls and Pitfalls
Reference
27: Case 6: Far-Lateral Approach for a Posterior Inferior Cerebellar Artery Aneurysm Clipping
Summary
Case Presentation
Approach
Alternatives
Positioning
Incision
Operation
Post-op
Outcome
Discussion
Pearls and Pitfalls
References
28: Case 7: Right Retrosigmoid Craniotomy for Microvascular Decompression for Trigeminal Neuralgia (Endoscope-Assisted)
Summary
Case Presentation
Approach
Alternatives
Anatomy
Positioning
Incision
Operation
Post-Op
Outcome
Pearls and Pitfalls
Discussion
Reference
29: Case 8: Right Retrosigmoid Craniotomy for Microvascular Decompression of Hemifacial Spasm
Summary
Case Presentation
Approach
Alternatives
Anatomy
Positioning
Incision
Operation
Post-op
Outcome
Pearls and Pitfalls
Discussion
Reference
30: Case 9: Left Retrosigmoid Craniotomy for Microvascular Decompression of Glossopharyngeal Neuralgia
Summary
Case Presentation
Approach
Alternatives
Anatomy
Positioning
Incision
Operation
Post-op
Outcome
Pearls and Pitfalls
Discussion
References
31: Case 10: Anterior Transpetrosal Approach for Resection of Petroclival Meningioma
Summary
Case Presentation
Approach
Alternatives
Anatomy
Positioning
Incision
Operation
Extradural Dissection: Subtemporal Corridor
Dura Opening
Tumor Resection
Closure
Post-op
Pearls and Pitfalls
References
32: Case 11: Vestibular Schwannoma Resection with Facial Nerve Displaced Dorsally
Summary
Case Presentation
Approach
Alternatives
Positioning
Incision
Operation
Anatomy
Post-op
Pearls and Pitfalls
References
33: Case 12: Right Retrosigmoid Craniotomy for Pontine Cavernous Malformation
Summary
Case Presentation
Approach
Alternatives
Anatomy
Positioning
Incision
Operation
Post-op
Outcome
Discussion
Pearls and Pitfalls
References
34: Case 13: Lateral Transcondylar Craniotomy for PICA Aneurysm
Summary
Case Presentation
Approach
Alternatives
Positioning
Incision
Operation
Post-op
Outcome
Discussion
References
35: Case 14: Left Retrosigmoid Approach in Large Vestibular Schwannoma in Patient with NF2
Summary
Case Presentation
Approach
Alternatives
Positioning
Incision
Operation
Post-op
Outcome
Discussion
Pearls and Pitfalls
36: Case 15: Retrosigmoid Approach for a Left-Sided Trigeminal Schwannoma
Summary
Case Presentation
Neurologic Exam
Approach
Alternatives
Positioning
Incision
Operation
Post-op
Outcome
Pearls and Pitfalls
37: Case 16: Retrosigmoid Approach to Right-Sided Epidermoid Cyst
Summary
Case Presentation
Approach
Alternatives
Positioning
Incision
Operation
Post-op
Outcome
Pearls and Pitfalls
38: Case 17: Translabyrinthine Transtemporal Approach for Left Vestibular Schwannoma
Summary
Case Presentation
Imaging
Approach
Alternatives
Positioning
Incision
Operation
Mastoidectomy
Labyrinthectomy
Dura Opening
Tumor Resection
Hemostasis and Closure
Post-op
Outcome
Pearls and Pitfalls
Discussion
39: Case 18: Middle Cranial Fossa Craniotomy for a Left Petrous Apex Lesion
Summary
Case Presentation
Imaging
Approach
Alternatives
Positioning
Incision
Operation
Soft Tissue Dissection
Craniotomy
Lesion Removal
Hemostasis and Closure
Post-op
Outcome
Pearls and Pitfalls
Discussion
40: Case 19: Extended Translabyrinthine Approach for Left-Sided Vestibular Schwannoma
Summary
Case Presentation
Imaging
Approach
Alternatives
Positioning
Incision
Operation
Mastoidectomy
Labyrinthectomy
Opening Dura
Tumor Dissection
Closure
Post-op
Outcome
Pearls and Pitfalls
Discussion
41: Case 20: Right-Sided Retrosigmoid Approach to Small Vestibular Schwannoma
Summary
Case Presentation
Approach
Alternatives
Positioning
Incision
Operation
Post-op
Outcome
Pearls and Pitfalls
Discussion
42: Case 21: Transotic Approach to Left-Sided Jugular Paraganglioma/Glomus Tumor for Partial Debulking
Summary
Case Presentation
Approach
Alternatives
Positioning
Incision
Operation
Post-op
Outcome
Pearls and Pitfalls
Discussion
Anatomic Dissection Appendix
Translabyrinthine and Transcochlear Approaches
Mastoidectomy
Translabyrinthine Approach
Labyrinthectomy
Transotic and Transcochlear Approach
Presigmoid/Retrolabyrinthine Approach
Middle Cranial Fossa Approach
Craniotomy and Extradural Dissection
Anterior Petrosectomy (Kawase Approach)
Index
