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J Neurol Surg B Skull Base 2016; 77(06): 485-490
DOI: 10.1055/s-0036-1584094
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Dual Endoscopic Endonasal Transsphenoidal and Precaruncular Transorbital Approaches for Clipping of the Cavernous Carotid Artery: A Cadaveric Simulation

Jeremy Ciporen
1   Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, United States
,
Brandon Lucke-Wold
2   Department of Neurosurgery, West Virginia University, Morgantown, West Virginia, United States
,
Aclan Dogan
1   Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, United States
,
Justin S. Cetas
1   Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, United States
,
William E. Cameron
3   Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, Oregon, United States
› Author Affiliations
Further Information

Publication History

04 January 2016

22 March 2016

Publication Date:
24 May 2016 (online)

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Abstract

Background Endoscopic skull base approaches are being used to address complicated neurovascular pathology. These approaches are safest when proximal vascular control of the cavernous carotid artery (CavCA) can be obtained.

Methods We present a cadaver-based anatomic simulation study showing the feasibility of clip placement for the CavCA as it courses through the cavernous sinus. The arterial vessels were injected with red microfil (Flow Tech, Carver, Massachusetts) to enhance visibility. The endoscope was directed through a precaruncular transorbital approach and instrumentation was managed through an endonasal transsphenoidal approach.

Results The dual approach minimized the “coning down” and instrument “sword fighting” that occurs as the rod lens endoscope and instruments are used laterally and posterior toward the clivus and brainstem. The precaruncular transorbital approach improved visualization of the clip application and improved the functional working area. The transorbital port allowed better appreciation of the distal clip tines, and the laterally positioned cranial nerves.

Conclusions The advantages may be most realized in the setting of endoscopic endonasal resection of highly vascular lesions and/or bleeding from a ruptured aneurysm being clipped. Simulated training provides an excellent opportunity to enhance skill sets and increase familiarity with anatomical visualization before entering the operative arena.

Keywords

cavernous carotid artery - CavCA - aneurysm clipping - simulation training - endonasal transsphenoidal approach - precaruncular transorbital approach
 

  • References

  • 1 Zacharia BE, Romero FR, Rapoport SK, Raza SM, Anand VK, Schwartz TH. Endoscopic Endonasal Management of Metastatic Lesions of the Anterior Skull Base: Case Series and Literature Review. World Neurosurg 2015; 84 (5) 1267-1277
    CrossrefPubMedGoogle Scholar
  • 2 Sekhar LN, Schramm Jr VL, Jones NF , et al. Operative exposure and management of the petrous and upper cervical internal carotid artery. Neurosurgery 1986; 19 (6) 967-982
    CrossrefPubMedGoogle Scholar
  • 3 Azar MM, Assi R, Patel N, Malinis MF. Fungal Mycotic Aneurysm of the Internal Carotid Artery Associated with Sphenoid Sinusitis in an Immunocompromised Patient: A Case Report and Review of the Literature. Mycopathologia 2015; (e-pub ahead of print). doi: 10.1007/s11046-015-9975-1
    PubMedGoogle Scholar
  • 4 Roopesh Kumar VR, Madhugiri VS, Sasidharan GM, Gundamaneni SK. Giant cavernous carotid artery aneurysm mimicking a fungal granuloma and presenting with massive epistaxis. BMJ Case Rep 2012; (e-pub ahead of print). doi: 10.1136/bcr-2012-006876
    PubMedGoogle Scholar
  • 5 Rangel-Castilla L, McDougall CG, Spetzler RF, Nakaji P. Urgent cerebral revascularization bypass surgery for iatrogenic skull base internal carotid artery injury. Neurosurgery 2014; 10 (Suppl. 04) 640-647 , discussion 647–648
    CrossrefPubMedGoogle Scholar
  • 6 Grigorian A, Rajaraman V, Hunt CD. Traumatic intracranial aneurysms complicating anterior skull base surgery. J Craniomaxillofac Trauma 1998; 4 (4) 10-14
    PubMedGoogle Scholar
  • 7 Reisch R, Perneczky A. Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery 2005; 57 (4, Suppl) 242-255 , discussion 242–255
    Google Scholar
  • 8 Sharma BS, Kumar A, Sawarkar D. Endoscopic controlled clipping of anterior circulation aneurysms via keyhole approach: Our initial experience. Neurol India 2015; 63 (6) 874-880
    CrossrefPubMedGoogle Scholar
  • 9 Heiferman DM, Somasundaram A, Alvarado AJ, Zanation AM, Pittman AL, Germanwala AV. The endonasal approach for treatment of cerebral aneurysms: A critical review of the literature. Clin Neurol Neurosurg 2015; 134: 91-97
    CrossrefPubMedGoogle Scholar
  • 10 Ceylan S, Anik I, Koc K, Ciftci E, Cabuk B. Endoscopic approach to cavernous sinus aneurysm. Turk Neurosurg 2013; 23 (3) 404-406
    PubMedGoogle Scholar
  • 11 Ronchetti G, Panciani PP, Cornali C , et al. Ruptured aneurysm in sphenoid sinus: which is the best treatment?. Case Rep Neurol 2013; 5 (1) 1-5
    CrossrefPubMedGoogle Scholar
  • 12 Xia X, Ramanathan M, Orr BA , et al. Expanded endonasal endoscopic approach for resection of a growth hormone-secreting pituitary macroadenoma coexistent with a cavernous carotid artery aneurysm. J Clin Neurosci 2012; 19 (10) 1437-1441
    CrossrefPubMedGoogle Scholar
  • 13 Benet A, Plata-Bello J, Abla AA, Acevedo-Bolton G, Saloner D, Lawton MT. Implantation of 3D-Printed Patient-Specific Aneurysm Models into Cadaveric Specimens: A New Training Paradigm to Allow for Improvements in Cerebrovascular Surgery and Research. Biomed Res Int 2015; 2015: 939387
    PubMedGoogle Scholar
  • 14 Hicdonmez T, Hamamcioglu MK, Tiryaki M, Cukur Z, Cobanoglu S. Microneurosurgical training model in fresh cadaveric cow brain: a laboratory study simulating the approach to the circle of Willis. Surg Neurol 2006; 66 (1) 100-104 , discussion 104
    CrossrefPubMedGoogle Scholar
  • 15 Davies J, Khatib M, Bello F. Open surgical simulation—a review. J Surg Educ 2013; 70 (5) 618-627
    CrossrefPubMedGoogle Scholar
  • 16 Ciporen JN, Moe KS, Ramanathan D , et al. Multiportal endoscopic approaches to the central skull base: a cadaveric study. World Neurosurg 2010; 73 (6) 705-712
    CrossrefPubMedGoogle Scholar
  • 17 Alaraj A, Luciano CJ, Bailey DP , et al. Virtual reality cerebral aneurysm clipping simulation with real-time haptic feedback. Neurosurgery 2015; 11 (Suppl. 02) 52-58
    PubMedGoogle Scholar
  • 18 Aboud E, Aboud G, Al-Mefty O , et al. “Live cadavers” for training in the management of intraoperative aneurysmal rupture. J Neurosurg 2015; 123 (5) 1339-1346
    CrossrefPubMedGoogle Scholar
  • 19 Marinho P, Vermandel M, Bourgeois P, Lejeune JP, Mordon S, Thines L. Preoperative simulation for the planning of microsurgical clipping of intracranial aneurysms. Simul Healthc 2014; 9 (6) 370-376
    CrossrefPubMedGoogle Scholar
  • 20 Lanza G, Vinciguerra L, Puglisi V , et al. Acute isolated trochlear nerve palsy in a patient with cavernous carotid aneurysm and visit-to-visit variability in systolic blood pressure. Int J Stroke 2015; 10 (6) E61
    CrossrefPubMedGoogle Scholar
  • 21 Aboud E, Al-Mefty O, Yaşargil MG. New laboratory model for neurosurgical training that simulates live surgery. J Neurosurg 2002; 97 (6) 1367-1372
    CrossrefPubMedGoogle Scholar
  • 22 Adeel M, Ikram M. Post-traumatic pseudoaneurysm of internal carotid artery: a cause of intractable epistaxis. BMJ Case Rep 2012; (e-pub ahead of print). doi: 10.1136/bcr.02.2012.5927
    PubMedGoogle Scholar
  • 23 Cappabianca P, Briganti F, Cavallo LM, de Divitiis E. Pseudoaneurysm of the intracavernous carotid artery following endoscopic endonasal transsphenoidal surgery, treated by endovascular approach. Acta Neurochir (Wien) 2001; 143 (1) 95-96
    CrossrefPubMedGoogle Scholar
  • 24 Cobb MI, Nimjee S, Gonzalez LF, Jang DW, Zomorodi A. Direct Repair of Iatrogenic Internal Carotid Artery Injury During Endoscopic Endonasal Approach Surgery With Temporary Endovascular Balloon-Assisted Occlusion: Technical Case Report. Neurosurgery 2015; 11 (Suppl. 03) E483-E486 , discussion E486–E487
    CrossrefPubMedGoogle Scholar
  • 25 Kalinin PL, Sharipov OI, Shkarubo AN , et al. Damage to the cavernous segment of internal carotid artery in transsphenoidal endoscopic removal of pituitary adenomas (report of 4 cases) [in Russian]. Vopr Neirokhir 2013; 77 (6) 28-37 , discussion 38
    PubMedGoogle Scholar
  • 26 Koitschev A, Simon C, Löwenheim H, Naegele T, Ernemann U. Management and outcome after internal carotid artery laceration during surgery of the paranasal sinuses. Acta Otolaryngol 2006; 126 (7) 730-738
    CrossrefPubMedGoogle Scholar
  • 27 Park AH, Stankiewicz JA, Chow J, Azar-Kia B. A protocol for management of a catastrophic complication of functional endoscopic sinus surgery: internal carotid artery injury. Am J Rhinol 1998; 12 (3) 153-158
    CrossrefPubMedGoogle Scholar
  • 28 Pawar SS, Loehrl TA, Michel MA, Fitzsimmons BF. Cavernous carotid pseudoaneurysm after endoscopic sphenoid mucocele marsupialization. Arch Otolaryngol Head Neck Surg 2010; 136 (4) 407-410
    CrossrefPubMedGoogle Scholar