PMC5299154_01
The pre and postoperative magnetic resonance images (MRI) of case 7. (a) Axial image of gadolinium (Gd)-enhanced T1-weighted MRI. Solid well-enhanced tumors exist in the interpeduncular cistern. (b) Saggital image of Gd-enhanced T1-weighted MRI. The tumor exists in the supradiaphragmatic space. (c) Coronal image of Gd-enhanced T1-weighted MRI. (d) Postoperative coronal image of Gd-enhanced T1-weighted MRI. The tumor has been removed completely
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F1
Surgical procedure of zygomatic arch osteotomy. (a) Two-layer skin flap elevation is performed. (b) The superficial fat pad is elevated with the temporal fascia. (c) The temporal muscle is freed from the temporal squama. The zygomatic arch is fully exposed and cut with a sagittal saw. (d) The posterior base of the zygomatic arch is cut with a sagittal saw. "T bone shape" zygomatic arch osteotomy is achieved. SF: superficial fad pad, TF: Temporal fascia, TM: Temporal muscle, ZA: Zygomatic arch
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F2
Two-layer skin flap elevation was performed [Figure 2a]. The superficial fat pad was elevated with the temporal fascia [Figure 2b]. The zygoma was then cut with a sagittal saw in a "T bone shape" [Figure 2c and 2d].
Surgical procedure of anterior clinoidectomy. (a) After zygomatic arch osteotomy, front-temporal craniotomy is performed. The temporal muscle is retracted inferoposteriorly. The lesser wing of the sphenoid bone is partially drilled, and the meningo-orbital band is identified (arrow). (b) Orbital unroofing is performed. (c) The superior orbital fissure and foramen ovale are identified. The meningo-orbital band is cut (arrow). (d) The temporal tip dura is peeled away from the anterior aspect of the cavernous sinus. SOF: Superior orbital fissure, FO: Foramen ovale, ACP: Anterior clinoid process, V1: Ophthalmic nerve, V2: Maxillary nerve
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F3
To make a "look up" operative field, orbital flattening is essential [Figure 3a and b]. The meningo-orbital band together with its vessels was then coagulated and divided over a distance of 3 to 5 mm, and a cleavage plane was established by sharp dissection between the dura propria of the temporal tip and the inner cavernous membrane [Figure 3c and d].
Surgical procedure of anterior clinoidectomy. (a) After drilling the inside of the anterior clinoid process (ACP), the ACP is removed using a small dissector. (b) After removing the ACP, the residual optic strut is drilled. The C3 portion of the internal carotid artery is identified. (c) The optic sheath is opened to decompress the optic nerve. (d) The operative view after anterior clinoidectomy, optic sheath opening, and proximal sylvian fissure opening. The tumor is identified in the opticocarotid space. OS: optic sheath, ACP: Anterior clinoid process, C3: C3 portion of the internal carorid artery, ON: Optic nerve, ICA: Internal caroid artery, M1: M1 portion of the middle cerebral artery, A1: A1 portion of the anterior cerebral artery, T: tumor
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F4
The anterior clinoid process was then carefully stripped from the surrounding fibrous adhesions using a small dissector, after which the remaining process was removed [Figure 4a]. The residual optic strut was then removed carefully by using microalligator forceps or drilling [Figure 4b]. The optic sheath was opened to decompress the optic nerve [Figure 4c]. The proximal sylvian fissure was opened [Figure 4d], and the anterior temporal artery was detached from the temporal lobe [Figure 5a].
Surgical procedure of extradural anterior temporal approach. (a) The anterior temporal artery (arrow) and deep middle cerebral vein (arrow head) is freed from the temporal lobe to retract the temporal lobe. (b) The arachnoid trabeculae between the oculomotor nerve and the temporal uncus are cut. The posterior communicating artery is identified (arrow head). (c) The temporal lobe is retracted posterolaterally. The retrocarotid space is widely secured. (d) The operative view in the simple trans-sylvian approach before performing the above 2 steps (a, b). The retrocarotid space is narrow and cannot be seen from lateral trajectory compared to c. ICA: Internal carotid artery, M1: M1 portion of the middle cerebral artery, III: Oculomotor nerve, P2: P2 portion of the posterior cerebral artery, T: Tumor, ON: Optic nerve
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F5
The proximal sylvian fissure was opened [Figure 4d], and the anterior temporal artery was detached from the temporal lobe [Figure 5a]. Then the arachnoid trabeculae between the oculomotor nerve and the temporal uncus were cut [Figure 5b], following which the temporal uncus could be retracted posterolaterally [Figure 5c and d].
Removal of the craniopharyngioma through both the opticocarotid space and the retrocarotid space. (a) The tumor is dissected from the optic tract (arrow head) via the optico-carotid space. A good "look up" operative view is achieved. (b) Internal decompression of the tumor from the opticocarotid space. (c) The tumor is dissected from the mammillary body through the retro-carotid space, inferior to the posterior communicating artery (arrow head). A good "look up" operative view is established. (d) Internal decompression of the tumor from the retro-carotid space through the superior and inferior space of the posterior communicating artery (arrow head). ON: optic nerve, T: tumor, ICA: Internal carotid artery, M1: M1 portion of the middle cerebral artery, m: Mammillary body, A1: A1 portion of the anterior cerebral artery, P1: P1 portion of the posterior cerebral artery, P2: P2 portion of the posterior cerebral artery
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F6
To remove the craniopharyngioma, the prechiasmatic space, opticocarotid space, and retrocarotid space should be used [Figure 6].First, the tumor capsule was identified, and internal decompression was performed [Figure 6b and d]. Then, the outer membrane of the tumor was carefully dissected from the surrounding normal structures [Figure 6a and c].
Identification of the cutting cleavage. (a) An inflammatory membrane covers both the tumor and normal tissue. The pial vessel (arrow head) belongs to the normal tissue. The dissecting plane is above the pial vessel. (b) The tumor capsule is identified and dissected from the normal structure. T: Tumor, m: Mammillary body, P1: P1 portion of the posterior cerebral artery, P2: P2 portion of the posterior cerebral artery
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F7
Sometimes, the tumor and the surrounding normal tissues are covered by an inflammatory membrane, and it is difficult to identify the dissection layer [Figure 7a]. After that, the dissection layer can be easily identified [Figure 7b].
Removal of the tumor and identification of normal structures. (a) The pituitary stalk is identified as a thin compressed membrane (arrow head). (b) The distended diaphragma sellae is identified. (c) The contralateral posterior clinoid process (arrow) and oculomotor nerve (arrow head) are identified after removing the tumor. (d) All normal structures are secured after removal of the tumor. A1: A1 portion of the anterior cerebral artery, ICA: internal carotid artery, ON: optic nerve
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F8
The pituitary stalk can sometimes be seen as a thin, compressed membrane [Figure 8a and b], and should be preserved during the operation.
Postoperative MRI and size of craniotomy. (a) Tumor was totally removed. (b) Size of craniotomy
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F9
Postoperative MR images and size of craniotomy are shown in Figure 9.