Increasing exposure of the petrous internal carotid artery for revascularization using the transzygomatic extended middle fossa approach: a cadaveric morphometric study

James K Liu, Takanori Fukushima, Tetsuro Sameshima, Ossama Al-Mefty, William T Couldwell
Neurosurgery 2006, 59 (4): ONS309-18; discussion ONS318-9

OBJECTIVE: When internal carotid artery (ICA) sacrifice is planned in the management of difficult tumors or aneurysms at the cranial base, the petrous ICA may be a useful site for anastomosis for interpositional vascular bypass. However, exposure of the artery and performing an anastomosis in this region may be technically challenging because of the narrow working corridor. The authors describe a transzygomatic extended middle fossa approach that maximizes the exposure of the petrous ICA for performing the difficult anastomosis.

METHODS: Bilateral dissections were performed on eight silicone-injected cadaveric head specimens. Exposure of the entire petrous ICA (horizontal segment, genu, and vertical segment) using the transzygomatic extended middle fossa approach was performed by the following steps. A frontotemporal craniotomy was performed followed by a zygomatic osteotomy. The temporal lobe dura was elevated extradurally to expose the posterior cavernous sinus and floor of the middle fossa. The middle fossa rhomboid was identified, which is bordered by V3 anteriorly, the GSPN laterally, the arcuate eminence posteriorly, and the petrous edge medially. Bone drilling was performed in the middle fossa rhomboid and Glasscock's triangle with care not to violate the cochlea. The horizontal and vertical segments of the petrous ICA were skeletonized entirely and mobilized from carotid canal. The V3 segment of the trigeminal nerve was retracted anteriorly to obtain more distal exposure of the ICA. An osteoplastic bone flap of the middle fossa floor lateral to the ICA was removed to increase the working space. A morphometric analysis was performed, quantifying the petrous ICA exposure, the surgical working corridor, and the angles of exposure.

RESULTS: On average, the length of the horizontal petrous ICA exposed was 9.2 +/- 1.0 mm (range, 8.0-11.0 mm). Anterior retraction of V3 provided an additional 4.3 +/- 0.4 mm of carotid exposure (46.7% increase; P < 0.05). The length of the genu was on average 3.6 +/- 0.4 mm (range, 3.0-4.0 mm), and the length of the vertical segment of the petrous ICA was 13.1 +/- 2.0 mm (range, 10.0-15.0 mm). The average depth of the petrous ICA from the outer surface of the temporal bone was 30.6 +/- 1.1 mm (range, 30.0-33.0 mm) at the V3-ICA junction and 27.2 +/- 0.7 mm (range, 26.0-28.0 mm) at the ICA genu. The average diameter of the inner working corridor was 24.2 +/- 3.0 mm (range, 21.5-30.0 mm). Removal of the zygoma increased the outer working corridor from an average distance of 24.4 +/- 3.8 mm to 33.4 +/- 3.4 mm (36.9% increase in exposure; P < 0.05). The average angle of exposure was 66.5% greater (P < 0.05) with zygomatic arch removal (39.3 +/- 4.9 degrees) than without zygomatic arch removal (23.6 +/- 2.7 degrees).

CONCLUSION: The transzygomatic extended middle fossa approach provides a wide surgical corridor for maximal exposure of the petrous ICA with minimized temporal lobe retraction. This large exposure facilitates vascular anastomoses at the petrous ICA and provides working room to maneuver instruments. The middle fossa rhomboid is a key landmark to identify the petrous ICA and to avoid neuro-otologic structures.

Full Text Links

Find Full Text Links for this Article


You are not logged in. Sign Up or Log In to join the discussion.

Related Papers

Remove bar
Read by QxMD icon Read

Save your favorite articles in one place with a free QxMD account.


Search Tips

Use Boolean operators: AND/OR

diabetic AND foot
diabetes OR diabetic

Exclude a word using the 'minus' sign

Virchow -triad

Use Parentheses

water AND (cup OR glass)

Add an asterisk (*) at end of a word to include word stems

Neuro* will search for Neurology, Neuroscientist, Neurological, and so on

Use quotes to search for an exact phrase

"primary prevention of cancer"
(heart or cardiac or cardio*) AND arrest -"American Heart Association"