Surgical management of lesions within the cavernous sinus.
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Adolescent↗
Biomedical subjects
C N Sen
Publications and source records attributed to C N Sen.
Recordings from the facial nucleus in the rat: signs of abnormal facial muscle response.
On the basis of results of electrophysiological studies in patients undergoing microvascular decompression (MVD) operations to relieve hemifacial spasm (HFS), we have postulated that the abnormal muscle response characteristically found in patients with HFS is the result of irritation of the facial nerve by the blood vessel that is compressing the facial nerve near its exit from the brainstem in these patients. This abnormal muscle response is seen when one branch of the facial nerve is electrically stimulated and recordings are made from muscles that are innervated by other branches of the facial nerve. We further hypothesized that the facial nucleus is hyperactive in patients with HFS and that the spasm and the abnormal muscle response are results of a phenomenon known as "kindling". These hypotheses are supported by recent studies showing that chronic electrical stimulation of the facial nerve trunk in rats near the brainstem results in an abnormal muscle response that is similar to that seen in patients with HFS. In this paper, we present the results of recording from the facial motonucleus in rats that had been subjected to repeated electrical stimulation of the facial nerve. The results indicate that the abnormal muscle response in these rats was caused by changes in the function of the facial motonucleus. We interpret these results as showing that the physiological abnormalities that give rise to the signs of HFS in man are located in the facial motonucleus, and that the changes in the function of the nucleus are produced by chronic antidromic neutral activity resulting from close contact between a blood vessel and the facial nerve.
Animals↗
An extreme lateral approach to intradural lesions of the cervical spine and foramen magnum.
Meningiomas and neurofibromas are the most common intradural extramedullary tumors of the foramen magnum and cervical spine. Many of these tumors are located ventral or ventrolateral to the spinal cord and medulla. Posterior approaches, although adequate for the management of most of these tumors, can sometimes result in incomplete removal of the tumor and exacerbation of the neurological deficits. Although the transoral and transcervical approaches provide a direct route to the tumor, the exposure of the lateral margins in the case of large tumors is inadequate. In addition, because of the removal of vertebral bodies, subsequent fusion may be necessary. In the present report, an extreme lateral approach to the foramen magnum and cervical spine for the removal of intradural tumors is described. The approach provides a lateral exposure of the tumor-cord/stem interface, thus permitting safe dissection without retraction of the cord. The entire longitudinal and lateral extent of the tumor and also its extradural extension can be can be managed by this approach. This approach can be considered in such a group of patients harboring entirely ventral or recurrent tumors for which the conventional posterior approach has failed. Six patients who underwent this procedure are described to illustrate its application.
Adolescent↗
Facial translocation: a new approach to the cranial base.
Nasopharynx, clivus, and cavernous sinus are difficult regions of the cranial base in which to perform oncologic surgery. We have developed an approach to this area by using facial soft tissue translocation and craniofacial osteotomies. Surgical field obtained at the skull base can extend from the contralateral eustachian tube to ipsilateral geniculate ganglion. It includes the nasopharynx, clivus, sphenoid, and cavernous sinus, as well as the entire infratemporal fossa and superior orbital fissure. Our experience with this technique in 12 patients is reported. All patients healed primarily.
Face↗
Anterior cranial base reconstruction: role of galeal and pericranial flaps.
Reconstruction of surgical defects in 30 patients undergoing surgery of the anterior cranial base was performed using pericranial, galeopericranial, and galeal scalp flaps. Twenty-seven patients had resection of neoplasms, the majority of which were malignant. Fifty-seven percent of patients received prior therapy consisting of surgery and/or radiotherapy. Adequate healing of the cranial base was noted in all cases without persistent cerebrospinal fluid leaks, meningitis, or brain herniation. Mucosalization of the intranasal surface was noted. No skin grafts were used. At a median follow-up of 13 months, 67% of patients were alive with no evidence of disease. The pericranial, galeopericranial, and galeal flaps are highly reliable, versatile, and well suited for reconstruction of the anterior cranial base.
Adolescent↗
Saphenous vein graft bypass of the cavernous internal carotid artery.
Saphenous vein graft reconstruction was performed from the petrous to the supraclinoid internal carotid artery (ICA) to replace the cavernous ICA in six patients during direct intracavernous operations. Four of these patients had intracavernous neoplasms with invasion of the ICA and two had intracavernous ICA aneurysms that could not be clipped or occluded with intraluminal balloons. All but one patient had evidence of poor collateral flow reserve in a balloon occlusion test of the ICA. The superficial temporal artery was not present in four patients, was minuscule in one, and was damaged during the initial dissection in another, making it unsuitable for superficial temporal-to-middle cerebral artery branch anastomosis. Blood flow within the graft could not be established intraoperatively in one patient (who had excellent collateral circulation) due to the small size of the vein (3 mm). In all others, the grafts were patent on follow-up arteriography and transcranial Doppler studies. Three patients who had severe reduction of cerebral blood flow during test occlusion of the ICA exhibited temporary hemispheric neurological deficits postoperatively; the deficits were related to the duration of temporary ICA occlusion. All three recovered completely without evidence of infarction on computerized tomography (CT). One patient who clinically could not tolerate the balloon occlusion test of the ICA also had temporary neurological deficits with good recovery but showed evidence of border-zone infarction on CT scans. The present role of saphenous vein graft bypass of the cavernous ICA is discussed.
Adult↗
The subtemporal and preauricular infratemporal approach to intradural structures ventral to the brain stem.
The subtemporal and preauricular infratemporal operative technique is an approach to the skull base through the anterior portion of the petrous temporal bone and is used for the removal of predominantly extradural tumors in this region. The present study, based on dissection of human cadavers, describes the use of this approach for the management of intradural lesions in the region of the clivus. Its main advantages include avoidance of brain retraction, the use of an extrapharyngeal route, and exposure of the ventral aspect of the pons and medulla and related structures caudal to the trigeminal root. This approach can easily be combined with an intradural subtemporal approach to provide additional exposure of the superior clivus rostral to the trigeminal root. Combining the two approaches provides direct access to the ventral surface of the entire brain stem from the dorsum sellae to the hypoglossal foramina. Five patients with lesions in the clivus and petrous apex have been operated on via this approach. Details of the anatomical aspects of the approach and its applications are presented.
Adult↗
Interposition vein grafts: cervical-to-petrous ICA bypass.
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Anastomosis, Surgical↗
Malignant skull base tumors.
A multidisciplinary approach to the treatment of malignant cranial base tumors has resulted in improved resections with less morbidity and a greater potential for cure. An improved understanding of the complex anatomy has allowed the development of new surgical approaches and improved methods of reconstruction. The authors' experience with the treatment of malignant neoplasms of the cranial base is reviewed, with emphasis on biologic behavior of this diverse group of neoplasms.
Craniotomy↗
Responses from dorsal column nuclei (DCN) in the monkey to stimulation of upper and lower limbs and spinal cord.
Responses from the dorsal surface of the exposed dorsal column nuclei (DCN) in baboons and a monkey (Macaca fascicularis) were recorded in response to electrical stimulation of the posterior tibial nerve at the ankle, the common peroneal nerve at the knee, the sciatic nerve, the spinal cord at T10, and the median nerve at the wrist. Recordings of far-field potentials from the vertex with a non-cephalic reference were made before exposing the DCN and simultaneously with recordings from the DCN. The response recorded from the DCN using a monopolar electrode to median nerve stimulation was a negative deflection (N wave) followed by a large and slow positive wave (P wave). The N wave was often preceded by a small positive deflection. The response from the median nerve to electrical stimulation of the DCN had the same latency as the initial positive peak and the initial portion of the N wave in the response from the DCN to stimulation of the median nerve, indicating that the initial positive peak was generated by presynaptic events in the DCN. The response recorded from the surface of the DCN to stimulation of the lower limbs consisted of many irregular waves followed by a large, positive deflection. Sometimes these irregular waves were superimposed on a small negative peak, and they were preceded by a positive deflection. The response from the tibial nerve to stimulation of the DCN consisted of a series of waves that had the same latency as the waves of the response from the DCN to stimulation of the tibial nerve.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Chordoma and chondrosarcoma of the cranial base: an 8-year experience.
Between 1980 and 1988, 8 patients with chordomas and 9 with low-grade chondrosarcomas involving the cranial base were treated. All the patients were investigated preoperatively and postoperatively with computed tomographic or magnetic resonance imaging scans, according to a standard protocol. The tumors and the involved bony structures were surgically removed in one or more operations using different operative approaches. Ten patients underwent postoperative radiation therapy, either at our institution or prior to their referral to us. Total removal was defined as the absence of identifiable tumor on magnetic resonance imaging or computed tomographic obtained 3 months postoperatively, and was accomplished in 9 patients. The ability to achieve total removal was greatly increased in patients with tumors that had not previously been operated on. We believe that these tumors must be treated by aggressive surgical resection when initially diagnosed, and this can be accomplished with low morbidity. The follow-up period in our patients was too short to allow us to determine whether such total removals can result in a cure or in long-term control of these formidable tumors.
Adolescent↗
Surgical treatment of intracavernous neoplasms: a four-year experience.
Forty-two patients with neoplasms involving the cavernous sinus had operations between 1983 and 1987. The lesions included 25 benign tumors (e.g., meningioma, neurilemoma) and 17 malignant tumors (e.g., chondrosarcoma, adenoid cystic carcinoma). The cavernous sinus was entered by inferior, anterolateral, or medial extradural approaches or by superior or lateral intradural approaches. The intracavernous internal carotid artery was managed by dissecting tumor away from it or by occlusion and excision with or without direct vein graft reconstruction, based on the results of a preoperative balloon occlusion test. Cranial nerves III, IV, V, and VI usually were dissected from tumor, but in 3 cases of tumor invasion, the excised nerve segment was reconstructed by direct suture or with a sural nerve interposition graft. Twenty-one of the benign tumors and 8 of the malignant tumors were excised totally and the remainder subtotally. On follow-up ranging from 3 to 48 months, one subtotally excised meningioma recurred and was treated with re-excision and adjuvant radiation therapy. Two "totally" excised malignant tumors recurred outside the cavernous sinus at the margins of excision. There was no operative mortality or permanent cerebral morbidity. Postoperatively, the ocular and neurological function of most patients was similar to the preoperative status; in some, it was significantly improved. Thirteen additional patients with intracavernous neoplasms also were evaluated during the same period and followed without operation. The early follow-up information regarding these patients is provided.
Brain Neoplasms↗
Epispinal stimulation of the spinal cord: a proposed method of operative monitoring.
By monitoring spinal cord function during surgical procedures in and around the spinal cord, vital information can be obtained regarding the integrity of this structure. However, the techniques currently used have several limitations. This paper describes a system of monitoring in the cat, whereby, using electrodes placed outside the spine for stimulation of the cord, reproducible responses can be recorded from a midline electrode tapped into the calvarium overlying the sensorimotor cortex. The levels of activation of the spinal cord achieved by direct stimulation of the cord through epidural electrodes and by the epispinal method were found to be similar. By studying the effects of various lesions on the epispinal evoked response, components in the recorded response were identified that were carried in all three funiculi of the cord; the changes produced by these lesions in the epispinal evoked response were immediate. In addition, the sensitivities of the epispinal evoked response and of the somatosensory evoked response to the lesions were compared. When the dorsal blood supply was interrupted, it became evident that, unlike the somatosensory evoked response, which monitors only the dorsal blood supply, the epispinal evoked response monitors both the dorsal and ventral blood supply. By evaluating the recorded response obtained using this method of monitoring, it was possible to identify the particular quadrant of spinal cord injury.
Animals↗
Signs of hemifacial spasm created by chronic periodic stimulation of the facial nerve in the rat.
We show in this paper that daily electrical stimulation of the facial nerve near its entrance to the brain stem in rats results in abnormalities in the electromyographic response of the facial muscles that resemble those seen in patients with hemifacial spasm. After about 4 weeks of daily electrical stimulation of the facial nerve for 1 min/day, stimulation of the temporal branch of the facial nerve resulted in an abnormal EMG response from the mentalis/orbicularis oris muscles, consisting of an initial deflection with a latency of about 6 ms, followed by a burst of EMG activity lasting 10 to 50 ms. We found such "lateral spread" of antidromic activity in all 10 rats that were subjected to chronic stimulation, but not in normal rats and not in rats that had electrodes implanted but which had not been stimulated. Measurements of neural conduction times suggest that the location of the cross transmission that gives rise to this lateral spread response is central to the site where the facial nerve exits the brain stem, probably in the facial motor nucleus. We take these results to support the hypothesis that chronic stimulation of the facial nerve can change the facial nucleus in such a way that it becomes hyperactive, and cross transmission between neurons that are innervating different facial muscles is facilitated.
Animals↗
Comparison of somatosensory evoked potentials recorded from the scalp and dorsal column nuclei to upper and lower limb stimulation in the rat.
Responses from the dorsal column nuclei (DCN) in the rat to stimulation of the upper limbs (median nerve) and lower limbs (sciatic nerve) showed a difference in the wave forms of the two responses. These results support results of earlier studies in the cat, monkey, and man that showed that only slow-conducting cutaneous afferents from the lower limbs travel in the dorsal column, while all afferents from the upper limbs travel in the dorsal column and synapse in the DCN. A comparison between the response from the DCN and that from the vertex to stimulation of the upper limbs showed correspondence between short-latency peaks, while no clear earlier waves could be discerned in the response from the vertex to stimulation of the lower limbs. Even when the dorsal column was transected on one side, the correspondence between the early peaks in the scalp and the DCN responses to stimulation of the upper limbs was maintained. The effect of the dorsal column lesion on the response recorded from the surface of the DCN to stimulation of the sciatic nerve was mainly a reduction in the number of peaks. Transection at the midbrain level resulted in elimination of the long-latency response in the scalp recording, but the initial negative peak was maintained, which corresponded to the initial negative peak of the DCN response to stimulation of the upper limbs.
Animals↗
Cavernous sinus tumors: neuroradiologic and neurosurgical considerations on 150 operated cases.
We reviewed the neuroimaging studies of 150 patients with cavernous sinus tumors operated on during an 8-year period. Meningiomas (66 cases), chordomas (18 cases), trigeminal neurolemmomas (12 cases), and chondrosarcomas (11 cases) were the most common diagnosed neoplasms. Neuroradiological findings are briefly described for each different kind of tumor encountered. The surgical impact of these findings is discussed.
Carotid Artery, Internal↗