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Sphenoparietal Sinus Transposition Technique: Optimization of the Surgical Corridor with Preservation of Prominent Bridging Vein

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Sphenoparietal Sinus Transposition Technique: Optimization of the Surgical Corridor with Preservation of Prominent Bridging Vein CLINICAL ARTICLE J Neurosurg 134:999–1005, 2021 Sphenoparietal sinus transposition technique: optimization of the surgical corridor with preservation of prominent bridging veins between the brain and the cranial base during aneurysm clipping via the pterional approach Takeya Niibo, MD,1 Katsumi Takizawa, MD,1 Jurou Sakurai, MD,1 Seizi Takebayashi, MD, PhD,1 Hiroyasu Koizumi, MD, PhD,1 Toru Kobayashi, MD, PhD,1 Rina Kobayashi, MD,1 Kouta Kuris, MD, PhD,1 Syusuke Gotou, MD,1 Ryousuke Tsuchiya, MD,1 and Hiroyasu Kamiyama, MD2 1Department of Neurosurgery, Asahikawa Red Cross Hospital, Asahikawa; and 2Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Japan OBJECTIVE The sylvian bridging veins between the brain and the dura on the inner surface of the sphenoid wing can restrict brain retraction for widening of the lateral retrocarotid space during clipping surgery for internal carotid artery (ICA)–posterior communicating artery (PCoA) and basilar apex (BX) aneurysms. In such cases, the authors perform extradural anterior clinoidectomy with peeling of the temporal dura propria from the periosteal dura and inner cavernous membrane around the superior orbital fissure, with the incision of the dura mater stretching from the base of the tem- poral side to just before the distal dural ring of the ICA (termed by the authors as the sphenoparietal sinus transposition [SPST] technique). This technique displaces the bridging segment of the sylvian vein posteriorly and enables widening of the surgical space without venous injury. In this study, the authors observed the operative nuances and investigated the usefulness of this technique. METHODS The authors retrospectively reviewed the medical charts of 66 consecutive patients with ICA-PCoA and BX aneurysms between January 2016 and July 2018. This technique was performed in 8 patients (5 patients with PCoA an- eurysms and 3 with BX aneurysms) in whom the bridging segments of the sylvian veins between the brain and the skull base restricted brain retraction for widening of the surgical space. The surface areas of the lateral retrocarotid space and the aneurysm were measured at the most visible working angle before and after the SPST technique was performed. RESULTS With the use of the SPST technique, an adequate surgical space for aneurysm clipping was obtained with preservation of the bridging veins in all patients. The mean surface areas of the lateral retrocarotid space (p = 0.002) and aneurysm (p = 0.001) were significantly increased from 18.3 ± 18.8 and 2.8 ± 2.5 cm2 before to 64.2 ± 21.1 and 20.9 ± 20.6 cm2, respectively, after the SPST technique was performed. CONCLUSIONS The SPST technique enables displacement of the bridging segments of the sylvian veins without ve- nous injury and enables widening of the surgical space around the lateral retrocarotid area. https://thejns.org/doi/abs/10.3171/2020.1.JNS192823 KEYWORDS anterior clinoidectomy; anterior clinoid process; paraclinoid; skull base; vascular disorders HE pterional-transsylvian approach is one of the via the pterional-transsylvian approach.1 In addition, this most versatile and commonly performed approach- approach is frequently used in clipping surgery for upper es during clipping surgery for intracranial aneu- basilar artery aneurysms.2,3 In clipping surgery for these Trysms. Internal carotid artery (ICA)–posterior commu- aneurysms, the surgical corridor involves the lateral retro- nicating artery (PCoA) aneurysms are typically repaired carotid space, which is accessed via the space between the ABBREVIATIONS ACP = anterior clinoid process; BX = basilar apex; DMCV = deep middle cerebral vein; FBBV = frontobasal bridging vein; fSSV = superficial sylvian vein with frontal lobe tributaries; ICA = internal carotid artery; MOB = meningo-orbital band; PCoA = posterior communicating artery; SOF = superior orbital fissure; SPS = sphenopa- rietal sinus; SPST = sphenoparietal sinus transposition; SSV = superficial sylvian vein; TPV = temporopolar vein; tSSV = superficial sylvian vein with temporal lobe tributaries. SUBMITTED October 16, 2019. ACCEPTED January 13, 2020. INCLUDE WHEN CITING Published online March 20, 2020; DOI: 10.3171/2020.1.JNS192823. ©AANS 2021, except where prohibited by US copyright law J Neurosurg Volume 134 • March 2021 999 Unauthenticated | Downloaded 09/29/21 12:00 AM UTC Niibo et al. skull base and brain. The superficial sylvian veins (SSVs), nent bridging vein between the brain and the dura on the which represent one of the three dominant venous drain- inner surface of the sphenoid bone obstructed brain re- age systems of the lateral cerebrum, usually course from traction for widening of the surgical space (Figs. 1–4), the the brain to the dural sinus along the sphenoid wing to arachnoid membrane that wrapped the vein was peeled drain into the sphenoparietal sinus (SPS).4 In other words, away from the vein to make the veins more stretchable these veins can pose an obstacle for accessing aneurysms. (denuding technique). 5 If the brain retraction was still re- Therefore, the bridging veins are occasionally sacrificed stricted even after these manipulations, we utilized the during dissection.5,6 Although clinical complications SPST technique. caused by intracranial venous sacrifice are rare,7 sacrifice The SPST technique is described here and shown in of these veins can cause venous congestion, hemorrhage, Video 1. and edema in cases in which the sacrificed veins that are VIDEO 1. SPST technique. The sylvian vein segments bridging damaged during surgery are involved in major drainage between the brain and the skull base restricted brain retraction pathways.6,8,9 At present, there is no established method for for widening of the retrocarotid space. In addition, brain retrac- predicting the consequences of sacrificing the veins. Thus, tion caused bleeding from the dural entrance of the sylvian vein. surgeons should aim to preserve intracranial veins while Therefore, we returned to the epidural space and unroofed the reserving a wide enough space within the surgical field for lesser wing of the sphenoid bone overlying the superior orbital fissure (SOF) and the inferolateral wall of the SOF around the safe manipulation. meningo-orbital band (MOB). The MOB was cut and the dura We retrospectively reviewed 8 cases of ICA-PCoA and propria was peeled from the periosteal dura and inner cavernous basilar apex (BX) aneurysms treated with clipping sur- membrane until the anterior clinoid process (ACP) was exposed. geries via the pterional-transsylvian approach, in which The ACP was removed with microrongeurs in a piecemeal fashion. the bridging segment of the sylvian veins between the The incision of the dural flap was stretched from the temporal base brain and the skull base restricted the ability to obtain side to the distal dural ring of the ACP. The bridging segment of the adequate surgical spaces for aneurysm clipping, while sylvian veins combined with the dural entrance of these veins is dis- sacrifice of these veins was considered to be associated placed posteriorly and the retrocarotid space is markedly widened. with high risks for venous complications. In all of these Copyright Asahikawa Red Cross Hospital. Used with permission. Click here to view. patients, we used a technique that enabled displacement of the bridging segment of the sylvian veins posteriorly The following procedures were carried out under micro- without venous injury, which resulted in obtaining ad- scopic magnification. The frontal dura was elevated from equate surgical corridors. We have termed this maneu- the anterior cranial fossa, and the orbital roof was flat- ver the “sphenoparietal sinus transposition (SPST) tech- tened with a power drill to gain a wider working space. nique.” In this report we describe the operative nuances The temporal dura was dissected from the temporal bone of this technique and our investigation of the validity until the lateral margin of the superior orbital fissure of this method for widening of the surgical corridor by (SOF) was exposed. The roof of the SOF was skeleton- quantifying the exposure enhancement of the surgical ized and the meningo-orbital band (MOB) was exposed working area. (Fig. 1B). The lesser wing of the sphenoid bone overlying the SOF and the inferolateral wall of the SOF, which is Methods part of the greater wing of the sphenoid bone, was un- roofed with a power drill. This step provides mobility for The present study was preapproved by the institutional the MOB and enables dissection of the dura propria from review board at our institution. the lateral inferior aspect of the anterior clinoid process (ACP) with a microdissector (Fig. 1C). After these maneu- Patient Population vers, it was possible to identify a cleavage plane that de- We retrospectively reviewed all cases of ICA-PCoA veloped between the frontal dura propria and the temporal and BX ruptured and unruptured aneurysms surgically dura propria at the MOB (Fig. 1D). This structure allows treated at our institution from January 2016 to July 2018. estimation of the thickness of the dura propria and the This review resulted in 66 patients (59 patients with ICA- correct layer between the dura propria and the periosteal PCoA and 7 patients with BX aneurysms) treated with dura. Peeling of the temporal dura propria from the peri- surgical clipping via the pterional-transsylvian approach. osteal dura was then started at this cleavage plane of the In 8 of these 66 patients (12%), approaching the lateral ret- MOB and continued
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