Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_4368_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

29.08.2026

Размер:

98 Мб

Скачать

☆

<<< < Предыдущая 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 4243 / 4443 44 > Следующая >>>

Pericranial and Temporoparietal Fascia Flaps

https://t.me/med1917

2. Before elevating the pericranial flap, a Draf III frontal sinusotomy (i.e., endoscopic Lothrop) is performed. This helps maintain frontal sinus drainage and will prevent the formation of a frontal sinus mucocele postoperatively. Mark a coronal incision at the vertex of the scalp, extending from one ear to the other (Fig. 37.1a). Depending on the goals of resection, the marked incision may be carried inferiorly and anteriorly in the preauricular region to allow increased mobility of the flap. Placing the incision at the vertex prevents transection of anterior branches of the superficial temporal artery supplying the anterior scalp and is cosmetically superior especially if there is some potential future for hair loss (e.g., young males with possible hairline recession).

3. Inject the marked incision line with a solution of 1% lidocaine with 1:100,000 epinephrine.

4. Carry the incision down to the cranium from one temporal line to the other (Fig. 37.1b).

5. Lateral and inferior to the temporal line, the incision is carried down to the superficial layer of the deep temporal fascia, which is continuous with the periosteal layer of the cranium (Fig. 37.1c).

6. Minimize bleeding applying Rainey clips at the edges of the incision. Alternatively, any significant bleeding point is cauterized using a bipolar electrocautery.

7. Elevation of the pericranium attached to the scalp flap prevents desiccation of the pericranial flap and also allows inclusion of the subaponeurotic tissue (loose areolar tissue) in the flap, thus making it more robust (Fig. 37.1d).

8. The scalp is then elevated in an anterior direction to reach and expose the superior orbital rim, paying attention to the fact that the supraorbital neurovascular pedicle may arise from a foramen or a notch (Fig.

37.1e). If there is a complete foramen, the supraorbital neurovascular pedicle may be freed via an inverted-V osteotomy performed with a 2- to 3-mm osteotome to prevent traction injury to the pedicle

9. The pericranial flap is then raised in a subgaleal plane using tenotomy scissors (Figs. 37.1f, 37.2, 37.3a).

10. As previously mentioned, care must be taken near the superior orbital rim to avoid transecting the penetrating branch of the supratrochlear and supraorbital arteries, which may arise 10 mm above the orbital rim (Fig. 37.1e).

a b

Fig. 37.1 (a) Bicoronal incision from ear to ear; incision may be extended in the preauricular region to increase mobilization of scalp

ﬂ ap. (b) Incise to the cranium from one temporal line to contralateral temporal line. (c) Deep temporalis fascia (asterisk), which is continuous with the periosteum (dashed arrow: elevated with scalp ﬂ ap), is incised to allow elevation of the scalp ﬂ ap in the same plane. (d) Elevated scalp with the pericranial ﬂ ap within the scalp ﬂ ap (asterisk) at this point (arrow: deep temporalis fascia). (e) Scalp ﬂ ap elevated to the supraorbital rim showing bilateral supraorbital pedicle (asterisks). (f) Pericranial ﬂ ap (in forceps) elevated from the overlying loose areolar tissue.

395

Pericranial and Temporoparietal Fascia Flaps

https://t.me/med1917

a b c

Fig. 37.2 (a) Bilateral bipedicled pericranial ﬂ ap elevated in forceps. (b) Two pericranial ﬂ aps pedicled on the ipsilateral neurovascular bundles (dashed arrows – ﬂ aps may be tapered towards the pedicle to improve mobilization of the ﬂ ap). (c) Osteotomy in the nasion. (d) Flap is transposed through the nasion osteotomy. (e) Flap is supported with an endonasal bolster.

11. A high-speed drill is used to open a 1 mm × 15 mm osteotomy at the nasion. This will communicate the coronal approach and frontonasal area with the endonasal anterior skull base resection site (Fig. 37.3b).

12. The flap is carefully transposed through the nasion osteotomy into the nasal cavity avoiding any rotation of the pedicle (Fig. 37.3c).

13. An endonasal bolster is placed to support the flap (Fig. 37.3d).

14. The coronal incision is closed meticulously in a multilayered fashion

15. Postoperatively, do not apply any pressure dressing over the orbital rim to avoid compression of the vascular pedicle.

37.2.5 Variations

1. Step 4 may be modified if an extended resection

Fig. 37.3 The pericranial ﬂ ap is raised in a subgaleal plane using tenotomy scissors

mandates a longer flap such as to incise down to the loose areolar tissue and then dissect posteriorly prior to incising down to the pericranium.

396

Pericranial and Temporoparietal Fascia Flaps

https://t.me/med1917

2. Note that the pericranium has bilateral neurovascular pedicles; however, a pericranial flap may be supported by only one neurovascular pedicle. Variations include raising a wide flap that use both pedicles (Fig. 37.3e), as is the preference when a transcranial or subfrontal approach is performed; raising two separate flaps with their own separate pedicles; or raising a single sided flap.

37.3 Transpterygoid

Temporoparietal Fascia Flap

37.3.1 Indications

The transpterygoid TPF flap is a regional vascularized pedicled flap that comprises the strong fascial layer connecting the overlying fibrous septae of the subcutaneous tissue in the temporoparietal region of the scalp. This flap offers a large surface area of pliable tissue with a very consistent and reliable vascular anatomy. A transpterygoid tunnel permits the transposition of the flap from the temporal to the infratemporal fossa, to be advanced into the nasal cavity through an expanded pterygopalatine fossa.

The transpterygoid TPF flap is most useful for the reconstruction of large defects of the posterior and middle cranial base when intranasal vascularized flaps are not feasible or when the extent of the defect mandates the use of multiple flaps. In particular, the transpterygoid TPF flap will cover middle cranial fossa, clival, parasellar, and planum sphenoidale defects.

However, tunneling the pedicle through the pterygopalatine fossa limits coverage of anterior skull base defects such as the cribriform plate.

37.3.2 Contraindications

Careful consideration is necessary in any patient who has undergone a prior rhytidectomy, excision of scalp lesions, coronal incision, parotid surgery, suffered a fractured zygoma, and in any patient with giant cell arteritis and/ or one who has undergone a superficial temporal artery biopsy. As this flap requires an external incision, it does have the potential risk of alopecia in the region of the scar. A transpterygoid TPF flap should also be avoided in a patient who has undergone irradiation of the scalp due to the risk of scalp necrosis.

37.3.3 Anatomy

The transpterygoid TPF flap is based on the anterior branch of the superficial temporal artery, a terminal branch of the external carotid artery, and one or two accompanying veins that usually run superficial to the artery. This superficial temporal artery runs posterior to the temporomandibular joint, crosses the posterior portion of the zygomatic root, and ascends anterior to the tragus of the ear. parietal branches approximately 3 cm above the arch of the zygoma to supply the skin overlying the temporalis fascia, the fascia itself, and the temporalis muscle.

The TPF (also known as the superficial temporal fascia) is directly continuous with the superficial musculoaponeurotic system inferiorly and the galea superiorly (Fig. 37.4). The TPF is thick (2–3 mm in the parietal region) and com-

It divides into its terminal frontal and

prises a surface area as large as 17 × 14 cm extending in a fanlike manner from the preauricular region.

9,11

tion, when elevated as a transpterygoid TPF flap, it offers a long vascular pedicle and a robust blood supply.

Care must be taken when elevating this flap to preserve frontal branches of the facial nerve that travel beneath (or rarely within) the TPF and superficial to the superficial layer of the deep temporalis fascia (Fig. 37.4). Topographically, the frontal branch runs along a line drawn from 5 mm below the tragus to a point approximately 1.5 cm above the lateral aspect of the ipsilateral eyebrow.

37.3.4 Surgical Steps

13,14

1. Creating a “window” for flap transposition.

a. The nasal cavity is decongested and prepared as

previously described (see Section 37.2.4, transfrontal pericranial flap technique step 1).

b. A endoscopic transmaxillary approach to the

pterygopalatine and infratemporal fossae is undertaken to create a window for the flap to be tunneled from the infratemporal fossa into the nasal cavity.

13,14

c. The flap is harvested ipsilateral to a transpter-

ygoid endonasal approach, which facilitates its transposition into the nasal cavity (contributes to the corridor).

Subcutaneous fat

Deep temporal fascia

Hair

Superficial

temporal

fascia

Frontal branch

of facial nerve

Ear

Facial nerve

Parotid

masseter fascia

Skin

SMAS

Fig. 37.4 Schematic demonstrating the relationship of the frontal branch of the facial nerve to the temporoparietal fascia/ superﬁ cial temporal fascia and superﬁ cial layer of the deep temporalis fascia. (Reproduced with permission of: Neligan PC, Rodriguez ED, Losee JE. Plastic Surgery: Volume Three: Craniofacial, Head and Neck Surgery Pediatric Plastic Surgery.

(2012). Oxford, UK: Elsevier.)

Temporal bone

Temporalis

Sentinel vein Middle temporal

fat pad

Zygomatic arch

Coronoid process of mandible

Masseter

In addi-

397

Pericranial and Temporoparietal Fascia Flaps

https://t.me/med1917

d. A large maxillary antrostomy and anterior

and posterior ethmoidectomies facilitate the transpterygoid transposition.

e. Identify and ligate the ipsilateral sphenopalatine

artery at the level of the sphenopalatine foramen. Remove the posterior wall of the maxillary sinus using Kerrison rongeurs to expose the pterygopalatine fossa.

f. The pterygomaxillary fissure may be expand-

ed by additional removal to include the lateral wall of the maxillary sinus, thus widening the communication with the infratemporal fossa (Fig. 37.5).

g. Inferior displacement of the soft tissues within

the pterygopalatine fossa exposes the anterior aspect of the pterygoid process. This requires the transection of the vidian neurovascular bundle.

h. Be cautious not to injure the internal maxillary

artery during this manoeuver.

i. Reduction of the most anterior aspect of the lat-

eral pterygoid plate with a high-speed drill further enlarges the corridor for the transposition of the transpterygoid TPF flap.

2. Elevation of TPF flap. a. Prior to the incision, a Doppler probe can be

used to identify the location of the superficial temporal artery.

b. Extend a hemicoronal incision down to the level

of the hair follicles only. Elevate the skin flap in a subdermal/subfollicular plane anterior and posterior to the incision leaving the TPF attached to the cranium (Fig. 37.6a).

c. Identify the parietal and frontal branches of the

superficial temporal artery. d. Incise the margins of the TPF flap (Fig. 37.6b). e. Elevate the TPF flap in a plane between the TPF

and the temporalis fascia. The portion of the flap

over the skull is incised down through the peric-

ranium. Once enough surface area is exposed, in-

cise the fascia at its lateral margins and elevate it

down to its pedicle (Fig. 37.6b). To preserve the

frontal branch of the facial nerve, ensure this dissection does not extend anterior to an imaginary line drawn between the tragus and the lateral eyebrow. By narrowing the pedicle of the flap at the level of the zygomatic arch, the temporal/frontal branches of the facial nerve may be spared.

Fig. 37.5 Schematic demonstrating removal of the lateral wall of the maxillary sinus during the creation of the transpterygoid tunnel. The temporoparietal fascia ﬂ ap has been transposed into the left nasal cavity. The ﬂ ap is shown positioned over a clival dural defect. (This ﬁ gure is provided courtesy of Bhatki et al. 201010.)

Fig. 37.6 (a) Intraoperative photograph demonstrating elevation of the skin ﬂ ap in a subdermal/subfollicular plane leaving the temporoparietal fascia attached to the cranium. (b) Exposure of the temporoparietal ﬂ ap via a hemicoronal incision followed by elevation of the skin in a subdermal plane. (These images are provided courtesy of Bhatki et al 201010.)

398

Incision in temporoparietal fascia

Scalp incision

Superficial temporal artery

Pericranial and Temporoparietal Fascia Flaps

https://t.me/med1917

3. Creation of an infratemporal/transpterygoid tunnel. a. Incise the superficial layer of the deep temporal

fascia vertically 2 to 3 cm above the zygomatic arch and separate it from the temporal muscle (Fig. 37.7). Extend this dissection inferiorly, thus elevating the periosteum from the medial surface of zygoma (Fig. 37.8).

b. Elevate the anterior edge of the temporalis mus-

cle from the lateral orbital wall and pterygomaxillary fissure. Expose the lateral wall of the

Temporoprietal fascia

Incision in superficial layer of deep temporal fascia

Fig. 37.7 Developing a plane superﬁ cial to the deep temporal fascia for the portion of the ﬂ ap over the temporalis muscle. Vertical incision of the superﬁ cial layer of the deep temporal fascia 2 to 3 cm above the zygomatic arch. (This ﬁ gure is provided courtesy of Bhatki et al. 201010.)

maxilla and remove any additional bone necessary to further develop the soft tissue tunnel through the infratemporal fossa.

c. This creates a communication between the

temporal, infratemporal, and pterygopalatine fossae. This tunnel may be expanded using percutaneous tracheostomy dilators passed over a guide wire passed deep to the zygomatic arch and through the maxillary defect (Figs. 37.9 and 37.10). The other end of the guide wire is grasped endoscopically.

d. Lateral canthotomy may be created to further

facilitate separation of the temporalis muscle between the zygoma and the lateral wall of the orbit (Fig. 37.11).

e. After an adequate tunnel is opened, attach

the flap (with sutures) to the external end of the guide wire that has been passed through the transpterygoid tunnel from the temporal fossa into the nasal cavity. As the nasal end of the guide wire is pulled out through the nostril, the flap will be drawn through the tunnel into the nasal cavity (Figs. 37.5 and 37.12). Avoid rotating of the flap or pedicle, which may compromise the blood supply.

f. Excessive pressure over the pedicle will stop the

venous outflow; therefore, the tunnel should have no constricting points.

g. When placing and bolstering the flap over the

defect, avoid any compression of the flap or pedicle, especially over each bony edge, change of direction or bend where they are most vulnerable.

h. Close external incisions with a single layer of

4–0 sutures or staples after the insertion of a

suction drain. Place absorbable packing, such as NasoPore (Polyganics) or nonadherent material, as the first layer adjacent to the repair/flap. If the patient is taking anticoagulants,

Fig. 37.8 Intraoperative photograph demonstrating elevation of the periosteum from the medial surface of zygoma (asterisk) during the creation of an infratemporal/transpterygoid tunnel.

Fig. 37.9 Intraoperative photograph demonstrating the creation and expansion of a communication between the temporal, infratemporal and pterygopalatine fossae. This tunnel may be expanded using percutaneous tracheostomy dilators (arrow) passed over a guide wire.

399

Pericranial and Temporoparietal Fascia Flaps

https://t.me/med1917

Dilator

Fig. 37.10 (a) Drawing, (b) intraoperative endoscopic view, (c) and external view of guide wire and dilator being advanced into nasal cavity. (Reproduced with permission of Fortes et al 200711.)

Fig. 37.11 Intraoperative photograph demonstrating the lateral canthotomy with dissection of the temporalis muscle between the zygoma and the lateral orbital wall.

b ca

has undergone resection of a vascular lesion, or required extensive hemostasis throughout the operation, then an absorbable hemostatic packing such as thrombin-soaked gelatin granules (e.g., Floseal, Baxter International) may be placed in the region of concern. These are followed by nonabsorbable packing, such as expandable sponges (Medtronic Inc.), which are placed firmly against the repair site. We do not favor the use of Foley catheters as they do not provide even pressure throughout the skull base and nasal cavity, may cause pressure necrosis, and its pressure may be transmitted to neurovascular struc-

15,16

tures. doscopic visualization 5 to 7 days after surgery, which implies an outpatient visit. Immediately after surgery,

We generally remove the packing under en-

400

Fig. 37.12 A transpterygoid tunnel is created to

accommodate the ﬂ ap. (This image is provided courtesy of Bhatki et al 201010.)

patients are encouraged to spray their nose with saline at least three times daily while the packing remains in place. After the packing is removed, the patients commence saline irrigations three or more times daily with a high-volume, low-flow device such as an irrigation bottle.

37.4 Discussion

Several vascularized flaps exist for the reconstruction of skull base defects. The current dilemma is in the selection of the most appropriate vascularized flap in varying clinical situations. We have described the indications, contraindications, anatomy, and surgical technique for the

Pericranial and Temporoparietal Fascia Flaps

https://t.me/med1917

TPF and transfrontal pericranial flaps. The transpterygoid TPF flap is ideal to reconstruct middle and posterior skull base defects, whereas the transfrontal pericranial flap is ideal for anterior skull base defects.

A transpterygoid TPF flap is not well suited for anterior skull base defects, as a significant part of its length is lost tunneling the flap through the pterygopalatine fossa. Similarly, the transfrontal pericranial flap is not recommended for posterior defects, as it would require sacrifice of the ethmoid sinuses, septum, and possibly olfaction. However, the biggest disadvantage of both of these extranasal flaps is the need for external incisions with their potential additional associated morbidity (i.e., forehead paresthesia, paresis of the frontal branch of the facial nerve, alopecia, unsightly scar). Regardless, mastering of the skills of extranasal or regional vascularized flaps is fundamental as they offer reconstructive alternatives, particularly when the posterior pedicle nasoseptal flap is not an option, when open approaches are needed, or when intranasal vascularized flaps are not available.

References

1. Kassam AB, Thomas A, Carrau RL, et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008; 63(1, Suppl 1):ONS44–ONS52, discussion ONS52–ONS53

2. Yoshioka N, Rhoton AL Jr. Vascular anatomy of the anteriorly based pericranial flap. Neurosurgery 2005; 57(1, Suppl):11–16, discussion 11–16

3. Price JC, Loury M, Carson B, Johns ME. The pericranial flap for reconstruction of anterior skull base defects. Laryngoscope 1988;98(11):1159–1164

4. Smith JE, Ducic Y. The versatile extended pericranial flap for closure of skull base defects. Otolaryngol Head Neck Surg 2004;130(6):704–711

5. Patel MR, Stadler ME, Snyderman CH, et al. How to choose? Endoscopic skull base reconstructive options and limitations. Skull Base 2010;20(6):397–404

6. McMinn RMH, ed. Last’s Anatomy: Regional and Applied. 9th ed. London: Churchill Livingstone

7. Saran S, Mohandas Rao KG; Ashwini LS; Mohandas Rao KG; Somayaji SN. Morphological and morphometric analysis of supraorbital foramen and supraorbital notch: a study on dry human skulls. Oman Med J 2012;27(2):129–133

8. Patel MR, Shah RN, Snyderman CH, et al. Pericranial flap for endoscopic anterior skull-base reconstruction: clinical outcomes and radioanatomic analysis of preoperative planning. Neurosurgery 2010;66(3):506–512, discussion 512

9. David SK, Cheney ML. An anatomic study of the temporoparietal fascial flap. Arch Otolaryngol Head Neck Surg 1995;121(10):1153–1156

10. Bhatki AM, Pant H, Snyderman CH, et al. Reconstruction of the cranial base following endonasal skull base surgery: regional tissue flaps. Operative Techniques Otolaryngology--Head and Neck Surgery 2010;21(1):83–90

11. Fortes FS, Carrau RL, Snyderman CH, et al. Transpterygoid transposition of a temporoparietal fascia flap: a new method for skull base reconstruction after endoscopic expanded endonasal approaches. Laryngoscope 2007;117(6):970–976

12. Larrabee WF Jr, Makielski KH. Surgical Anatomy of the Face. New York, NY: Raven Press; 1993

13. Kassam AB, Gardner P, Snyderman C, Mintz A, Carrau R. Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa. Neurosurg Focus 2005;19(1):E6

14. Cavallo LM, Messina A, Gardner P, et al. Extended endoscopic endonasal approach to the pterygopalatine fossa: anatomical study and clinical considerations. Neurosurg Focus 2005;19(1):E5

15. Weber R, Keerl R, Hochapfel F, Draf W, Toffel PH. Packing in endonasal surgery. Am J Otolaryngol 2001;22(5):306–320

16. Klinger M, Siegert R. Microcirculation of the nasal mucosa during use of balloon tamponade. Laryngorhinootologie 1997;76(3):127–130

17. Snyderman CH, Janecka IP, Sekhar LN, Sen CN, Eibling DE. Anterior cranial base reconstruction: role of galeal and pericranial flaps. Laryngoscope 1990;100(6):607–614

401

https://t.me/med1917

Index

https://t.me/med1917

Page numbers in italics refer to illustrations; those in bold refer to tables

abducens nerve 12, 14, 16, 173, 175, 177,

213, 296, 301, 310, 310, 318–319, 325–328, 333, 335–337, 336–338, 341, 343–344, 351

decompression 220 injury during surgery 214 median approach 351–352, 351–352 palsy 212

paramedian approach 352–353, 354 “above and below” approach 215 abscess

intracranial 91

orbital 149, 150 accessory nerve 12, 17, 309, 311, 341,

343, 344

median approach 355 acoustic meatus, internal 339, 343, 344 agger nasi 23, 32, 45 alveolar nerve, inferior 183 ambient cistern 344 aneurysm

anterior communicating artery 131

posterior inferior cerebellar artery 212,

214

angiofibroma, juvenile 250, 255 anterior commissure 111 anterior petrosectomy see petrous apex anterior transpetrosal approach 316

case example 320, 320

complications 318

indications 316

technique 316, 317–318 anteromedial corridor approach 166, 348

abducens nerve 351–353, 351–352

accessory nerve 355

anatomic considerations 166

case example 177, 178–179

complications 177

facial nerve 355

glossopharyngeal nerve 355

hypoglossal nerve 355–357

indications 166

nasal cavity approach 167–174

lateral paramedian expansion

170–174, 171–174

rostrocaudal binasal rectangular

midline nasal exposure 167–169,

167–170

oculomotor nerve 350–353

olfactory nerve 348–349, 348

optic nerve 349–350, 349–350

preparation 166–167

trigeminal nerve 351, 351, 352–353

trochlear nerve 351, 352–353

vagus nerve 355

vestibulocochlear nerve 355

see also Meckel’s cave/diverticulum aqueduct of Sylvius 112 arcuate eminence 318 as

terion 305, 307 atlanto-occipital membrane 234, 234, 309 atlas 14, 306–310

C1–C2 subluxation 223, 228–229 embryonal development 225–226 transverse process 305, 305–308 see also craniovertebral junction (CVJ)

auditory artery, internal 344 auditory canal

external 182 internal 182, 316, 318

autofluorescence imaging 275

basal lamellae 23, 32, 33

removal 34–35

basilar artery 12, 14–16, 109–110, 113,

183, 186, 213, 310, 310–312, 318–319, 330–331, 333–334, 339, 339–344, 341–345

anatomy 343–345, 343–344 transclival corridor 342–343 transplanum supra-retrosellar corridor

341–342 basilar impression 226 basilar invagination 226–227 basilar plexus 214, 333, 339

injury during surgery 214 basisphenoid vascular network 251, 252 basopharyngeal fascia resection 233,

233, 235

Bernasconi–Cassinari artery 135, 326,

326, 327 buccal nerve 240–242, 241, 242 bulbopontine sulcus 12 bulla ethmoidalis 8, 10, 23–32, 34–35, 39,

41, 42, 68, 69, 79, 132

anterior wall 31–32 basal lamella 70 intact bulla technique 41 opening 132

C1 see atlas C1–C2 subluxation 223, 228–229 calcarine artery 345 canthal tendon

lateral 156, 157 medial 156, 157

carcinoma

maxillary sinus 263, 263 Meckel’s diverticulum 177, 178

nasopharynx 187, 189, 268, 269 caroticoclinoid ligament 329 carotid artery see internal carotid artery carotid canal 182, 184, 186, 274

exposure 186 carotid foramen 182 carotid plexus 311 carotid protuberance 107, 119, 120, 121,

122, 130, 309, 312

parasellar 201 carotid sheath 244

fascia 243, 244 caudomedial artery 344 cavernous sinuses 185, 326, 328,

335–337, 336–339 anatomy 337–338 arteries to 135 nerves 136–137 opening 135, 136, 139 surgical approach 14, 128

case example 139–140, 140 complications 140–141

indications 128

surgical steps 128–138, 129–139 thrombosis 57 tumors 128

cerebellar artery

anterior inferior 12, 14, 16, 213–214,

310, 318–319, 339, 343–344, 343–344

pos

terior inferior 12, 16–17, 213, 306,

340–342, 341

aneurysm 212, 214 superior 12, 14–15, 109–110, 213, 310,

310, 318, 330–331, 334–335, 339,

342–344, 342–344 cerebellum 299, 300, 309 cerebral artery

anterior 86, 86, 103, 131, 329–332, 330,

333–334, 334–335

postcommunicating tract 109

precommunicating tract 109 middle 330, 331, 334–335, 335 posterior 12, 109–110, 213, 310, 310,

330–331, 334–335, 339, 342, 342–344, 344–345, 354–355

cerebral peduncle 213 cerebral vein, anterior 330 cerebrospinal fluid (CSF) leak

postoperative 89–91, 112, 140, 214,

229–230

prevention 121, 383 repair 89–91, 299 sphenoid fistula 55, 56

chiasm see optic chiasm chiasmatic cistern 106 chiasmatic sulcus 96, 97, 100, 101 choana 55, 117–120, 211, 360 cholesterol granuloma, petrous apex 187,

hordoma

choroid plexus 111, 111, 113, 309 choroidal artery, anterior 330, 331,

ciliary arteries 148, 149

ciliary nerves 137, 148

circle of Willis 334, 335, 345 circular sinus 337 circuminfundibular plexus 331, 333 cistern

clinoidectomy, posterior 203, 203 clival line

clival recess 95–97, 99–102, 184, 362, 363 clivocarotid protuberance 211

, 188, 195, 195

187

clival 212, 214, 219, 220–221, 235,

236–238, 297

craniovertebral junction 220, 224–225,

228–229

332–333, 334, 335

injury during surgery 149 posterior 148

long 149

injury during surgery 151

ambient 344 chiasmatic 106 interpeduncular 203–204, 310, 354 lamina terminalis 106, 108, 108, 109 prepontine 310

inferior 318 superior 318

341, 342,

Index

https://t.me/med1917

clivus 10, 13, 107, 119, 122, 183, 201, 211,

212, 294, 294, 309, 312, 318, 318, 341

inferior third 232, 294, 319

resection 234, 234 see also far medial approach to the

inferior third of the clivus

lesions 232

chordoma 212, 214, 219, 220–221,

235, 236–238, 297

meningioma 219, 222–223 middle portion 294–295, 294, 296 resection 203, 203 upper portion 294, 294, 296, 298 see also craniovertebral junction (CVJ);

transclival approach cochlea 182, 183 collateral vein 148, 149 commissure

anterior 111 habenular 112 interthalamic 111, 113 posterior 112, 319

communicating artery

anterior 86, 103, 109, 122, 330,

330–332, 334, 335, 354–355

aneurysm 131

posterior

ommunicating vein, anterior 330 coronoid process 183 cranial fossa

anterior 333

dural exposure 285, 286 dural resection 286, 287 middle 333, 361

posterior 333, 343

cranial nerves 14–17, 136–137, 300–301,

cavernous sinus 136 see also specific nerves

craniopharyngioma 204–205, 204–205

infundibular 111, 112 cranioplasty 289, 290 craniotomy 287, 289

suboccipital 306, 307–308, 312 craniovertebral junction (CVJ) 218, 225,

dissection 307

pathologies 218, 218, 225–229

surgical approaches 14, 218

103, 110, 205, 310, 330–331,

332, 333, 333–335, 342, 342–344

median approaches 348–349, 348,

349

paramedian approaches 350, 350

median approaches 350–352,

351–353

paramedian approaches 352–355,

354

paramedian approaches 357

348

341

chordoma 219, 220, 220–221,

225–226, 228–229

developmental anomalies 225–228 infections 229 neoplastic disease 228–229 rheumatoid disease 228 spinal cord compression 220,

226–227

trauma 228

avoidance of complications 224,

229–230, 312

case examples 219, 220–221,

220–225, 311, 312–313

combined approach 311

far lateral approach 304–306,

305–309

transnasal transpharyngeal approach

219–221, 224–225

transnasal transsphenoidal approach

218–219, 220–223

transoral approach 221–223,

228–229

ibriform plate 47, 72, 86, 87, 284

opening of 88, 88 crista ethmoidalis 77, 78, 171, 171 crista galli 86, 88, 289, 330–331

removal 285, 285, 330–331 CT scan 8

Denker’s approach 271, 271–273 dentate ligament 309 diaphragma sellae 319, 355 digastric sulcus 300 distal osseous arch 362, 364 Dorello’s canal 326, 327, 351, 351 dorsum sella 109, 113, 113, 203, 205, 333,

335–336, 339–340

resection 203, 203, 353 Draf type I procedure 40, 41, 41, 42 Draf type IIa procedure 40, 41, 41, 43 Draf type IIb procedure 40, 41, 41, 43, 47 Draf type III procedure 38, 40, 43–44, 45,

46, 282, 283

dura mater 14, 16, 122

anterior skull base 285–286

exposure 285, 286 resection 286, 287

clival 193

extended approach to the

ventrolateral brain stem 310–311,

310–311

far lateral approach 306, 309 transclival approach 212, 212–213

emissary vein 299, 299, 300 Enterococcus faecalis infection 55

esthesioneuroblastoma 44, 47, 290, 291 ethmoid sinus 22, 51

anterior 23, 28

posterior 23, 54

roof 22, 23, 32, 34, 35

surgery 22–23

indications 22 infundibulotomy 23–24, 25–27 middle meatal antrostomy 27–28,

28–29