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Extended Endoscopic Endonasal Approaches for Cerebral Aneurysms: Anatomical, Virtual Reality and Morphometric Study

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Extended Endoscopic Endonasal Approaches for Cerebral Aneurysms: Anatomical, Virtual Reality and Morphometric Study Hindawi Publishing Corporation BioMed Research International Volume 2014, Article ID 703792, 9 pages http://dx.doi.org/10.1155/2014/703792 Research Article Extended Endoscopic Endonasal Approaches for Cerebral Aneurysms: Anatomical, Virtual Reality and Morphometric Study Alberto Di Somma,1,2 Matteo de Notaris,2,3 Vita Stagno,1,2 Luis Serra,4 Joaquim Enseñat,3 Isam Alobid,5 Joan San Molina,6 Joan Berenguer,7 Paolo Cappabianca,1 and Alberto Prats-Galino2 1 Department of Neurosciences, Reproductive and Odontostomatological Sciences, Division of Neurosurgery, Universita` degli Studi di Napoli Federico II, Via Sergio Pansini 5, 80131 Naples, Italy 2 Laboratory of Surgical Neuroanatomy (LSNA), Faculty of Medicine, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain 3 Division of Neurosurgery, Hospital Clinic de Barcelona, Faculty of Medicine, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain 4 Center for Computational Imaging & Simulation Technologies in Biomedicine (CISTIB), Information & Communication Technologies Department, Universitat Pompeu Fabra (UPF), Tanger` 122-140, 08018 Barcelona, Spain 5 Department of Otorhinolaryngology, Rhinology Unit, Hospital Clinic de Barcelona, Faculty of Medicine, Universitat de Barcelona, Villarroel 170, 08036 Barcelona, Spain 6 Medical Sciences Department, Faculty of Medicine, University of Girona, Emili Grahit 77, 17071 Girona, Spain 7 Department of Radiology, Neuroradiology Division, Hospital Clinic of Barcelona, Villarroel 170, 08036 Barcelona, Spain Correspondence should be addressed to Matteo de Notaris; [email protected] Received 30 April 2013; Accepted 24 October 2013; Published 19 January 2014 Academic Editor: Heather F. Smith Copyright © 2014 Alberto Di Somma et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. The purpose of the present contribution is to perform a detailed anatomic and virtual reality three-dimensional stereoscopic study in order to test the effectiveness of the extended endoscopic endonasal approaches for selected anterior and posterior circulation aneurysms. Methods. The study was divided in two main steps: (1) simulation step, using a dedicated Virtual Reality System (Dextroscope, Volume Interactions); (2) dissection step, in which the feasibility to reach specific vascular territory via the nose was verified in the anatomical laboratory. Results. Good visualization and proximal and distal vascular control of the main midline anterior and posterior circulation territory were achieved during the simulation step as well as in the dissection step (anterior communicating complex, internal carotid, ophthalmic, superior hypophyseal, posterior cerebral and posterior communicating, basilar, superior cerebellar, anterior inferior cerebellar, vertebral, and posterior inferior cerebellar arteries). Conclusion. The present contribution is intended as strictly anatomic study in which we highlighted some specific anterior and posterior circulation aneurysms that can be reached via the nose. For clinical applications of these approaches, some relevant complications, mainly related to the endonasal route, such as proximal and distal vascular control, major arterial bleeding, postoperative cerebrospinal fluid leak, and olfactory disturbances must be considered. 1. Introduction endovascular treatment as the preferred strategy. As a matter of fact, in many world renowned neurosurgical hospitals During the last decade, the management of intracranial and centers, endovascular coiling has replaced neurosurgical aneurysms has moved from neurosurgical clipping to clipping as the treatment of choice, when coiling is technically 2 BioMed Research International feasible [1]. Indeed, since the publication of the International The purpose of the present anatomic study is to verify Subarachnoid Aneurysm Trial, there has been a paradigm the usefulness of the extended endoscopic endonasal shakeup in the management of intracranial aneurysms, and approaches to access selected anterior and posterior circula- more aneurysms are referred for endovascular coiling [2]. tion aneurysms; in other words, the aim of the present feasi- What is apparent in the pertinent literature and discussions bility study is to determine and select cerebral circulation is that a substantial amount of controversy still exists regard- aneurysms that could be managed through the extended ing the best therapeutic strategy in patients with ruptured endoscopic endonasal approaches. aneurysms. As a matter of fact, in many centers world- The vascular exposure provided by the endonasal wide endovascular techniques majorly replaced surgery for approaches has been firstly analyzed using a preoperative 3D aneurysms; however, it is not possible to lay down definitive modelwiththeaidofadvancedvirtualrealitysystem,based rules for the lack of consensus studies. On the other hand, sin- on conventional computed-tomography angiography of adult gle institutions experiences have been recently published [3– patients with intracranial aneurysms arising from different 6]. In a recent single-center series, it was found that 87.5% of cerebral vascular regions. After that, six specimens were aneurysmal subarachnoid hemorrhage patients were treated dissected in the anatomical laboratory with the aid of a with endovascular techniques, while 12.5% with craniotomy neuronavigation system, in order to verify the vascular expo- and clip ligation, thus demonstrating the amount of shifting sure gained using the same surgical approaches. toward the endovascular therapy [7]. Specifically, three main routes were identified: the tran- Undoubtedly,thesuccessfuldevelopmentandimplemen- stuberculum-transplanum, the superior transclival, and the tation of endovascular therapy have led to a less invasive inferior transclival pathways. approach to cerebrovascular disease and the room for surgery has been progressively confined. 2. Materials and Methods On the other side, with the rapid development of the endoscopic endonasal technique, the interest in extended 2.1. Computed-Tomography Images Acquisition. All speci- transsphenoidal approaches has been renewed for many mens underwent a predissection computed-tomography scan pathological entities [8–10]. with a multislice helical acquisition protocol (slice thickness: ∘ Recently, few specialized centers offered to treat selected 0,6 mm; gantry angle 0 ); heads were positioned in the scan- patients through a less invasive approach, such as the ner (Siemens SOMATOM Sensation 64) in order to obtain a extended endoscopic endonasal. This new approach carries projection perpendicular to the palate. The images achieved a real clinical applicability and some papers have already been were subsequently stored into a PACS (Picture Archiving and published in the pertinent literature. Since the pioneering Communication System). innovative works presented by Kassam et al. [11, 12], a variety To allow the coregistration with the neuronavigation sys- of vascular lesions, mainly posterior circulation aneurysm, tem,fivescrewswereimplantedintheskullaspermanent have started to be approached through the transsphenoidal bone reference markers. route [13–19]. In particular, the transtuberculum-trans- planum route has been used in the recent years with the aim 2.2. The Dextroscope and Data Acquisition, Visualization, and of clipping aneurysms arising from the superior hypophy- Measurement. Before proceeding with the cadaveric dissec- seal, anterior communicating, ophthalmic, and paraclinoidal tion, a Virtual Reality System, known as Dextroscope (Dex- carotid arteries [12, 17–19]. In addition, concerning posterior troscope; Volume Interactions Pte. Ltd., Singapore), was used cerebral circulation aneurysms, other authors published cases to perform a virtual simulation of each surgical approach. of vertebral, basilar, and vertebral-posterior inferior cerebel- Such tool is a holographic imager that permits detailed anal- lar arteries aneurysms treated through endoscopic endonasal ysis of the skull base anatomy throughout integration and or microscopic sublabial transclival approach [11, 13–16]. fusion of multiple tomographic images series derived from Moreover, recent anatomical studies and clinical reports the multislice computed tomography. have detailed the extended endoscopic endonasal transsphe- It provides the opportunity to perform surgical planning noidal technique, demonstrating its utility for the manage- and decision making for different neurosurgical approaches ment of selected midline intracranial aneurysms. with the aim of evaluating the best one among them. The Applied to vascular surgery, the endoscopic endonasal surgeon can define and/or revise the trajectory or add a new approach offers some advantages due to the properties of path using interactive 3D visualization. Indeed, the virtual the endoscope itself; the endoscopic endonasal approach workspace inside the Dextroscope provides all the necessary offers the same benefits of the endoscopic-assisted microsur- tools for surgical planning. The hardware and software have gical technique used to treat cerebral aneurysms resulting been previously described exhaustively [20, 21]. in a better exposure “around the aneurysm” in order to The patient-specific radiology data sets were acquired and visualize blind corners, to preserve other vessels, and to processed as
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