Indocyanine green fluorescence visualizes landmark arteries for endoscopic sinus and skull base surgery.

OBJECTIVE: Landmark arteries during endoscopic sinus surgery are currently identified on the basis of anatomy, CT imaging and navigation, and Doppler flowmetry. However, the advantage of intraoperative fluorescence imaging during endoscopic sinus surgery has not been demonstrated. This study aimed to investigate whether Indocyanine Green (ICG) is useful for visualizing landmark arteries during endoscopic sinus and skull base surgery. METHODS: Eight patients who underwent endoscopic sinus and pituitary surgeries and consented to study participation were included. After planned procedures were performed as usual, landmark arteries were examined by ICG endoscope. Recorded video and preoperative CT images were analyzed for identification of five landmark arteries: anterior ethmoidal artery (AEA), posterior ethmoidal artery (PEA), internal carotid artery (ICA), sphenopalatine artery (SPA), and postnasal artery (PNA). Identification of arteries was evaluated three grades: identifiable, locatable, unrecognizable. RESULTS: Eight patients and eleven sides were evaluated. The ICG dose was 2.5 mg/body and a single shot was sufficient for evaluation. 100 % of AEA was identified (9/9 sides), 86 % of PNA (6/7 sides), 56 % of ICA (5/9 sides), and 25 % of PEA and SPA (2/8 sides). CONCLUSION: ICG could visualize landmark arteries, even thin arteries like AEA, during endoscopic sinus and skull base surgeries. Visualization was affected by thickness of bone or soft tissue above arteries, blood clots, sensitivity setting, and angle and distance of near-infrared light irradiation. ICG visualization of landmark arteries may help avoid vascular injuries during endoscopic sinus and skull base surgeries, particularly of AEA, PNA and ICA.

Asymmetry of the anterior ethmoidal artery in relation to the anterior skull base: a population-based study of 500 arteries.

OBJECTIVE: To analyze variability in the distance between the Anterior Ethmoidal Artery (AEA) and the anterior Skull Base (SB), as well as the frequency of lateral asymmetry in a Latin American population using computed tomography. METHODS: A total of 250 computed tomography scans of paranasal sinuses in coronal reconstruction (500 AEAs) were analyzed. After determining the image with the best anatomical view of the artery, the distance between its midpoint and the ethmoidal roof was measured, and the images were independently interpreted by 2 physicians. RESULTS: Of the 500 AEAs, 279 (55.8%) adhered to or passed through the SB at a distance of 0mm. A total of 221 AEAs (44.2%) were at some distance from the SB, of which 107 (48.4%) were on the right side, ranging from 1.18 to 6.75mm, and 114 (51.5%) were on the left side, ranging from 1.15 to 6.04mm. The overall mean distance between the AEA and SB was 1.22 (SD=1.57) mm, increasing to 2.77 (SD=1.14) when the arteries adhered to the SB were excluded. Seventy-six individuals (30.4%) had a lateral distance variation > 1mm. CONCLUSION: Our study includes the largest sample of AEA analyzed with computed tomography scans of paranasal sinuses. There was some distance between the AEA and SB in almost half the patients, and we found a high rate of lateral variability >1mm. LEVEL OF EVIDENCE: Level 3.

The petrosal artery and its variations: a comprehensive review and anatomical study with application to skull base surgery and neurointerventional procedures.

BACKGROUND: The petrosal artery supplies several structures at the skull base and is often the focus of various neurointerventional procedures. Therefore, knowledge of its anatomy and variations is important to surgeons and interventionalists. MATERIALS AND METHODS: Twenty latex injected cadaveric heads (40 sides) underwent microsurgical dissection of the petrosal artery. Documentation of the course of the artery and its branches were made. Measurements of the petrosal artery's length and diameter were performed using microcallipers. RESULTS: A petrosal artery was identified on all sides. The mean length and diameter of the artery within the middle cranial fossa was 2.4 cm and 0.38 mm, respectively. Branches included the following: dural, ganglionic, V3 branches, branches extending through the foramen ovale, branches directly to the greater petrosal and lesser petrosal nerves, branches to the floor of the hiatus of the greater and lesser petrosal nerves, branch to the arcuate eminence, and superior tympanic artery. No statistically significant differences were noted between male and female specimens, but right-sided petrosal arteries were in general, larger in diameter than left sides. CONCLUSIONS: A thorough anatomical knowledge of the petrosal artery and to its relationship to the facial nerve and other neurovascular structures is necessary to facilitate effective endovascular treatment and to preclude facial nerve complications.

Anatomy of the Dorsal Meningeal Artery Including Its Variations: Application to Skull Base Surgery and Diagnostic and Interventional Imaging.

BACKGROUND: The blood supply to the skull base is important to surgeons and those performing interventional and diagnostic procedures in this region. However, 1 vessel with a vast distribution in this area, the dorsal meningeal artery (DMA), has had few anatomic studies performed to investigate not only its normal anatomy but also its variations. Therefore the current study aimed to analyze the DMA via cadaveric dissection. METHODS: In 10 adults, latex-injected, cadaveric heads (20 sides), the DMA was dissected using a surgical microscope. This artery and its branches were documented and measured. RESULTS: A DMA was identified on all sides. In the majority (85%), it was a branch of the meningohypophysial trunk or common stem with either the inferior hypophysial or tentorial arteries and always had branches that traversed the basilar venous plexus. Multiple branches of the DMA were identified and categorized as bony, dural, neural, and vascular. CONCLUSIONS: Surgeons operating at the skull base or clinicians interpreting imaging of this area should have a good working knowledge of the DMA and its typical and variant anatomy.

Endovascular treatment for dural arteriovenous fistulas in the petroclival region.

Petroclival region dural arteriovenous fistulas (DAVFs) are rare and difficult lesions to manage. They often have very complex anatomical structures and can be further divided into the superior petrosal sinus, petrous apex, inferior petrosal sinus, upper clival, and upper clival epidural-osseous DAVFs. Most petroclival region DAVFs should be treated due to their high Cognard grades. Currently, endovascular treatment (EVT) has become the first-line therapeutic option for petroclival region DAVFs. But not all the petroclival region DAVFs could be cured with EVT. When the arterial feeders are large or the DAVF is adjacent to the venous sinus, the success rate may be higher. In petroclival region DAVFs, if EVT can be performed successfully, satisfactory outcome can be anticipated. However, there are some inadvertent complications, which include cranial nerve palsy, subsequent sinus thrombosis, and migration embolization of the internal carotid artery and vertebral artery. Currently, a review of the EVT of petroclival region DAVFs is lacking. In this article, we performed a review of the relevant literature on this issue. In addition, some illustrative cases would be provided to elaborate these specific entities.

Arachnoid and dural reflections.

The dura mater is the major gateway for accessing most extra-axial lesions and all intra-axial lesions of the central nervous system. It provides a protective barrier against external trauma, infections, and the spread of malignant cells. Knowledge of the anatomical details of dural reflections around various corners of the skull bases provides the neurosurgeon with confidence during transdural approaches. Such knowledge is indispensable for protection of neurovascular structures in the vicinity of these dural reflections. The same concept is applicable to arachnoid folds and reflections during intradural excursions to expose intra- and extra-axial lesions of the brain. Without a detailed understanding of arachnoid membranes and cisterns, the neurosurgeon cannot confidently navigate the deep corridors of the skull base while safely protecting neurovascular structures. This chapter covers the surgical anatomy of dural and arachnoid reflections applicable to microneurosurgical approaches to various regions of the skull base.

Development of an Experimental Model for Studying the Nasosinusal and Skull Base Arterial and Venous Systems Using Iodinated Contrast and Latex in Cadavers.

BACKGROUND: Cadaver dissection remains one of the most reliable and safest ways to study anatomy, whereas computed tomography angiography (CTA) is an essential technology for enabling students to become familiar with human anatomy and surgical planning. Thus, the convergence of both radiologic and anatomic information is important for surgical success, especially in regions of complex anatomy such as the nasosinusal and skull base regions. Here we propose an experimental model in formalinized cadaver heads consisting of intravascular injection of colored latex and iodinated contrast mixture, followed by CTA scans of the nasosinusal and skull base arterial and venous systems before dissection. METHODS: Six cadaver heads that had been preserved for >5 years in 10% formaldehyde were immersed for 72 hours in a solution containing a dimethyldiethanol mono/dialkyloyl ester quaternary ammonium salt. In 5 of these heads, a mixture composed of latex, tissue ink, and iodinated contrast (Ultravist 300) was injected into the vascular system. CTA scans were performed sequentially after the injection, followed by endonasal and macroscopic dissections. RESULTS: There was good radiologic and macroscopic vessel uptake in 4 specimens, allowing a detailed anatomic study. CONCLUSIONS: An experimental model was made feasible by injecting iodinated contrast and colored latex into formalinized cadavers for CTA evaluation of the nasosinusal and skull base arterial and venous systems before performing dissections.

In Vivo Computed Tomography Direct Volume Rendering of the Anterior Ethmoidal Artery: A Descriptive Anatomical Study

Abstract Introduction The clinical relevance of the anatomy and variations of the anterior ethmoidal artery (AEA) is outstanding, considering its role as a landmark in endoscopic surgery, its importance in the therapy of epistaxis, and the high risks related to iatrogenic injuries. Objective To provide an anatomical description of the course and relationships of the AEA, based on direct computed-tomography (CT)-based 3D volume rendering. Methods Direct volume rendering was performed on 18 subjects who underwent (CT) with contrast medium for suspected cerebral aneurism. Results The topographical location of 36 AEAs was assessed as shown: 10 dehiscent (27.8%), 20 intracanal (55.5%), 6 incomplete canals (16.7%). Distances from important topographic landmarks are reported. Conclusion This work demonstrates that direct 3D volume rendering is a valid imaging technique for a detailed description of the anterior ethmoidal artery thus representing a useful tool for head pre-operatory assessments.

Lateral nasal wall flap for endoscopic reconstruction of the skull base: anatomical study and clinical series.

BACKGROUND: The lateral nasal wall (LNW) flap provides vascularized endonasal reconstruction primarily in revision surgery. Although the harvesting technique and reconstructive surface have been reported, the arterial supply to the LNW flap and its clinical implications is not well defined. This study presents anatomical dissections to clarify the vascular supply to this flap, and the associated clinical outcomes from this reconstructive technique. METHODS: The course and branching pattern of the sphenopalatine artery (SPA) to the LNW were studied in 6 vascular latex-injected heads (11 LNW flaps total). Patients undergoing an LNW flap since 2008 were identified and the underlying pathology, indication, flap viability, and clinical outcomes were retrospectively analyzed. RESULTS: The inferior turbinate artery arises from the LNW artery and divides into 2 branches at the most posterior aspect of the inferior turbinate bone. A smaller-caliber superficial branch travels anteriorly and branches to the LNW. A larger dominant branch travels into the inferior meatus and tangentially supplies the nasal floor. Twenty-four patients with sellar or posterior cranial fossa (PCF) defects were reconstructed with an LNW flap. Postoperative contrast enhancement of the LWN flap was identified in 95.5% of cases. Postoperative cerebrospinal fluid (CSF) leaks were identified in 6 cases. CONCLUSION: Blood supply to the nasal floor by the dominant inferior meatus branch is more robust than the supply to the anterior LNW by the superficial arterial branch. The LNW flap is the preferred vascularized reconstructive option to the PCF and sella in the absence of a nasoseptal flap (NSF).

Radiologic analysis of the location, shape and size of the external aperture of the carotid canal in children.

OBJECTIVES: This retrospective computed tomography (CT) study was aimed to assess the growth dynamic of the external aperture of the carotid canal (EACC) in children aged between 1 and 20 years. METHODS: Two hundred patients (sex 100 females/100 males, average age 10.50 ± 5.77 years) with good head CT image quality were included in this study. CT images of the patients were used to obtain data related to the location, shape and dimension of EACC. RESULTS: EACC shapes were identified as oval shaped, round shaped, and tear-drop shaped in 58.3% (233 sides), 24% (96 sides) and 17.8% (71 sides), respectively. EACC length, disEACC-MSP (distance between EACC and midsagittal plane), and EACC width did not change from the prepubescence period; while, the disEACC-SC (distance between EACC and supramastoid crest) seemed to reach adult size in the postpubescence period. Linear functions for EACC length and width were calculated as: y = 5.453 + 0.091 × years, and y = 5.398 + 0.059 × years, respectively. CONCLUSION: The regression equations of the measured parameters representing the growth dynamic of EACC in children can be helpful to estimate its size, location and angulation, which suggest that the dimension and distances to certain anatomical landmarks seemed to reach adult size in different developmental periods. In this context, the findings of this study may seem to emphasize the importance of preoperative radiological evaluation on skull base, related to EACC, for multidisciplinary surgeon teams during childhood surgeries in terms of patients' positioning, and the selection of appropriate surgical approach.

Planning of Endocranial Supratentorial Basal Cistern and Skull Base Approaches Depending on Venous Patterns Using a Topogram.

BACKGROUND: Because damage or sacrifice of venous drainage during supratentorial basal cistern and skull base approaches may have severe and harmful consequences, methods to identify preoperatively veins at risk are of paramount importance. Among methods, a codified assessment with a venous topogram is helpful, with practical implications. METHODS: This technical note describes how to construct an easy-to-use topogram. Three regions of interest are defined as triangles. The anterior triangle corresponds to the anterior frontal veins draining to the superior sagittal sinus at risk during anterior cerebral fossa surgery, the middle triangle corresponds to the anterior sylvian veins draining to the cavernous sinus at risk during pterional approaches, and the inferior triangle corresponds to the inferior cerebral veins draining to the transverse sinus at risk in subtemporal approaches and temporal lobe surgery. RESULTS: Depending on predominance of the drainage, 4 situations were defined: an anterior, an inferior, and a middle predominance or equilibrium between the 3 triangles. These anatomic features have important practical implications in skull base and basal cistern approaches. CONCLUSIONS: This is, to our knowledge, the only topogram described in the scientific literature. Any well-defined approach should be adapted to the individual patient according not only to location and type of lesion but also to the venous drainage to be encountered along the way.

Diploic veins of the cranial base: an anatomical study using magnetic resonance imaging.

PURPOSE: The anatomy and distribution of the diploic veins (DVs) of the cranial base have not been fully documented. The aim of this study was to characterize these veins using contrast magnetic resonance imaging (MRI). METHODS: In total, 95 patients underwent thin-sliced, contrast MRI. Coronal and sagittal images were used for the analysis. The cranial base was divided into the anterior, middle, and posterior bases. Then, each base was further subdivided into three equal parts in the anteroposterior and lateromedial directions. The anteroposterior parts were evaluated on coronal images, while the lateromedial parts were evaluated on sagittal images. RESULTS: The DVs were identified over the entire cranial base. However, they were more frequent in the posterior-third of the lateral-third region of the anterior, middle-third of the lateral and middle-third regions of the middle, and middle-third region of the posterior cranial base, and sparse in the posterior and medial-third regions of the middle cranial base. The DVs showed marked morphological variability. For instance, the DVs of the pterional area were generally well defined, as pivotal channels connecting the lateral parts of the anterior and middle cranial base, but were highly varied in appearance. CONCLUSIONS: The DVs of the cranial base are distinct structures characterized by morphological variability and topographical predilection. Contrast MRI is useful for delineating these veins.

[Study of - maximum systolic velocities and mean maximum velocities of skull base arteries recorded with transcranial Doppler in adult sickle cell patients without neurovascular complication]. / Étude des vitesses systoliques maximales et des moyennes des vitesses - maximales des artères de la base du crâne enregistrées au Doppler transcrânien chez l'adulte drépanocytaire sans complication neurovasculaire.

INTRODUCTION: Sickle cell disease is the leading genetic disease in Île-de-France. Stroke is one of its most severe complications. In SS sickle cell children, transcranial Doppler (TDC) is, through the study of average speeds of the skull base arteries, the gold standard for screening and diagnosis of vasculopathy. To our knowledge, in adults with sickle cell disease, no standards have been established for the speed of the arteries at the base of the skull. It therefore seemed useful to us to establish an approach to brain speeds recorded in adults with sickle cell disorders without neurovascular complications. MATERIAL AND METHODS: This was an observational, prospective, monocentric study conducted between February 2017 and June 2017. The main objective of the study was to determine the mean and standard deviation of maximum systolic velocities (MSS) and mean maximum velocities for all arteries recorded during the transcranial Doppler echo. The secondary objectives were to compare the mean maximum systolic velocities in sickle cell adults with those of healthy adults, to compare the mean maximum systolic velocities in sickle cell adults with those of sickle cell children, and to determine whether parameters could influence the speeds recorded at TCD. RESULTS: Forty patients were included between February 1, 2017 and June 30, 2017, with an average age of 39.3 years. The mean maximum velocities recorded were: 78cm/s for the middle cerebral arteries; 59.6cm/s for the internal carotid arteries; 61cm/s for the anterior cerebral arteries; 44cm/s for the posterior cerebral arteries and 55cm/s for the basilar trunk. DISCUSSION: The highest circulatory velocities are found in the middle cerebral arteries. The speeds found in the internal carotid arteries and anterior cerebral arteries are faster than in the vertebrobasilar system. Speeds in sickle cell adults are slower than those described in sickle cell children SS but significantly faster than those found in healthy adults. CONCLUSION: To our knowledge, this study is the first to evaluate transcranial Doppler circulatory velocities in adult sickle cell patients. This work has limitations due to its small sample size, however, it provides a basis for further studies on transcranial Doppler in sickle cell adults.

Septal floor rotational flap pedicled on ethmoidal arteries for endoscopic skull base reconstruction.

OBJECT: Expanded endonasal approaches have dramatically changed how skull base surgery is performed, and nasoseptal flap (NSF) has significantly improved skull base reconstruction. However, challenges remain when the pterygopalatine artery is invaded by tumors; when it must be sacrificed to approach the lateral sphenoidal recess; when late-occurrence leak occurs in the sella after transsphenoidal surgery; and also when the leak is on the posterior wall of the frontal sinus, which is too distant for NSF to reach. This article describes a septal floor rotational flap pedicled on ethmoidal arteries for endoscopic skull base reconstruction in certain cases. STUDY DESIGN: Case series. METHOD: In this article, we retrospectively review a series of 19 patients who underwent skull base reconstruction with a septal floor rotational flap pedicled on the ethmoidal arteries. RESULT: All 19 flaps, including the anterior and posterior artery pedicled flaps, survived without significant complications, and no postoperative cerebrospinal fluid leak occurred during follow-up. CONCLUSION: Ethmoidal arteries pedicled septal floor rotational flap, with their strong blood supply and large coverage area, are ideal replacements for NSF. These flaps are qualified in locations ranging from the posterior wall of the frontal sinus to the lateral sphenoidal recess and in cases ranging from tumor invading the pterygopalatine fossa to sellar late-occurred leak after transsphenoidal surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2696-2701, 2019.

An undescribed venous pathway intervening between the olfactory fossa and nasal vestibule.

PURPOSE: A curvilinear pathway intervening between the olfactory fossa and nasal vestibule has not been well documented. Therefore, the aim of this study was to examine its structure using magnetic resonance imaging (MRI). METHODS: In total, 84 patients underwent thin-sliced, contrast MRI. Among these patients, 31 underwent additional thin-sliced, sagittal T2-weighted imaging. RESULTS: A curvilinear pathway intervening between the olfactory fossa and nasal vestibule was delineated on sagittal and coronal imaging in 98% and 82% of patients, respectively. All of these pathways demonstrated communication with the lower limit of the superior sagittal sinus (SSS) or fine venous channels connecting to the SSS in the vicinity of the crista galli. The pathway was identified in the parasagittal regions on both sides with varying lengths, diameters, and curvatures. In 94% of the patients who underwent sagittal T2-weighted imaging, the pathways appeared as linear high-intensity signals. Most pathways were delineated as a single channel coursing extracranially adjacent to the olfactory fossa. In 38% of the patients, post-contrast sagittal images showed variable filling defects between the olfactory bulb and floor of the olfactory fossa, furthermore traversing the venous pathway. Additionally, in 73% of the patients, post-contrast images identified diploic venous channels, variably in the nasal bone and communicating with the venous pathway. CONCLUSIONS: A curvilinear pathway intervening between the olfactory fossa and nasal vestibule is a consistent venous structure and may function as an extracranial route of cerebrospinal fluid drainage.

Utility of the Vidian Canal in Endoscopic Skull Base Surgery: Detailed Anatomy and Relationship to the Internal Carotid Artery.

OBJECTIVE: To investigate key anatomic features of the vidian canal that have a critical role in planning and performing endoscopic skull base surgeries. METHODS: We reviewed skull base computed tomographic images of 640 consecutive subjects. Studies were analyzed in axial, coronal and sagittal planes. RESULTS: The mean (±SD) length of the vidian canal was 15.4 ± 2.0 mm in female subjects and 16.6 ± 1.7 mm in male subjects, and the difference between genders was statistically significant (P < 0.001). The most common rostral-caudal course of the vidian canal was medial to lateral and was followed by the straight course, tortuous course, and lateral-to-medial course. The frequency of pneumatization pattern from most common to least common was types 0, III, II and I. Of 342 evaluated sides, the vidian canal was located below the level of the anterior genu of petrous ICA in 303 (89%) sides, at same level with the anterior genu of petrous ICA in twenty-five(7%) sides, and above the level of the anterior genu of petrous ICA in fourteen(4.1%) sides. CONCLUSIONS: A variety of previously undefined features of the vidian canal that can alter the course of surgical procedure were defined. The position of the vidian canal with respect to the petrous internal carotid artery (ICA) was extensively described. From a surgical standpoint, a working room inferior and medial to the vidian canal might not always be a safe approach, because the vidian canal could be located superior to the level of the anterior genu of petrous ICA according to our findings in the present study.

Anatomical variations of anterior ethmoidal artery at the ethmoidal roof and anterior skull base in Asians.

PURPOSE: The variations of the anterior ethmoidal artery (AEA) in different populations should be recognized by surgeons to prevent unwarranted complications during surgery. The aim of this study was to assess the anatomical variations of AEA in Asian population. METHODS: A cross-sectional study of 252 AEA identified by computed tomography (CT) of the paranasal sinuses. The multiplanar CT images were acquired from SOMATOM® Definition AS+ and reconstructed to axial, coronal and sagittal view at 1 mm slice thickness. RESULTS: 42.5% of AEA was within skull base (grade I), 20.2% at skull base (grade II) and 37.3% coursed freely below skull base (grade III). The prevalence of supraorbital ethmoid cell (SOEC) and suprabullar cell (SBC) was 29.8% and 48.0%. The position of AEA at skull base has significant association with SOEC (p < 0.001), but not with SBC (p = 0.268). Type I Keros was 42.1% and Type 11 Keros was 57.9%. When lateral lamella's height is longer, the probability increases for AEA to course freely within the ethmoid sinus (p = 0.016). The mean distance of AEA from skull base was 1.93 ± 2.03 mm, orbital floor 21.91 ± 2.47 mm and nasal floor 49.01 ± 3.53 mm. CONCLUSIONS: The position of AEA at skull base depends on the presence of SOEC and length of lateral lamella, but not with SBC. When compared to European population, the mean distance between AEA and nasal floor is shorter in Asians.

Skull Base Venous Anatomy Associated with Endoscopic Skull Base Neurosurgery: A Literature Review.

An understanding of the anatomy and function of the skull base venous channels is fundamentally important for safe performance of endoscopic surgery for skull base lesions. This review focuses on 4 skull base venous channels-namely, the intercavernous sinuses, basilar plexus, osseous veins, and inferior petroclival vein-because these have been less recognized by neurosurgeons than other major venous channels such as the inferior petrosal sinus. We reviewed the literature concerning these 4 venous channels and discussed their anatomy and function. The literature review was mainly based on an electronic search in PubMed using the following terms: "intercavernous sinus," "basilar plexus," "emissary veins," "diploic vein," "basilar plexus," "intraosseous vein," "inferior petroclival/petro-occipital vein," and "transclival." A total of 50 articles were included in this review. Detailed anatomic features of the 4 structures have been elucidated in the literature. All of these venous channels run along the skull base and have multiple connections with surrounding venous structures. Because of their location, they occasionally obstruct the surgical view and are sometimes implicated in intraoperative hemorrhage, air embolism during endoscopic skull base surgery, and postoperative hematoma. They usually function as a venous reservoir of cranial venous drainage; however, they are less often directly involved in normal brain perfusion. Knowledge about the functional and morphologic anatomy of the skull base venous channels is important for neurosurgeons to avoid unexpected complications during endoscopic skull base surgery.

[Variability and age-related features of the anatomy of the midline structures of the anterior skull base]. / Variabel'nost' i vozrastnye osobennosti anatomii sredinnykh struktur perednikh otdelov osnovaniia cherepa.

The article presents the literature data on the structural variability and age-related features of the midline anatomical structures of the anterior skull base (frontal sinus, ethmoid bone, anterior parasellar region, and medial orbital wall). This is the area of surgical interests of neurosurgeons and rhinosurgeons. The study objective is to analyze the literature data on the individual variability and age-related anatomy of these structures. The work is illustrated with original images from the authors' personal archive. The individual anatomical features of eloquent structures in the surgical area (structures within the surgical corridor, key anatomical landmarks, optic tract, internal carotid and ethmoidal arteries, etc.) should be considered in planning surgery in patients of all age groups because they can limit the view and the amount of safe manipulations or increase the risk of complications. The presented data may be useful for neurosurgeons and otolaryngologists whose surgical interests are focused on the midline structures of the anterior skull base.

Extra-small dual-lumen micro-balloon catheters can improve endovascular embolization: an experimental in vivo and in vitro study.

BACKGROUND: The embolization technique can have significant impact on the success of endovascular embolization. OBJECTIVE: To evaluate the feasibility, embolization characteristics, and embolization extent with a newly developed extra-small micro-balloon catheter in an in vivo and in an in vitro embolization model in comparison with standard microcatheter embolizations. MATERIALS AND METHODS: Twenty-eight embolization procedures were performed in the porcine rete mirabile (RM) and in an in vitro embolization model, using either an extra-small (distal outer diameter 1.6 F) dual-lumen micro-balloon catheter or a standard microcatheter. Precipitating hydrophobic injectable liquid (PHIL) was used as embolic agent. Procedure times, number of injections, required volume of embolic agent, and embolization extent (percentage of embolized RM in postinterventional X-ray scans or number of filled sections of the in vitro model) were assessed. Histopathological analyses were performed. RESULTS: Total procedure time was significantly shorter (in vivo: 123 s vs 615 s (medians), P=0.001; in vitro: 180 s vs 496 s (medians), P=0.001), number of reflux events was significantly lower (in vivo: 0 vs 9 (medians), P=0.001; in vitro: 0 vs 3 (medians), P=0.001), and embolization extent was significantly higher (in vivo: 96.9% vs 65.6% (medians), P=0.011; in vitro: 26 vs 18 filled sections (medians); P=0.041) for the micro-balloon catheter groups. There was antegrade movement of the PHIL cast after balloon deflation in one in vitro embolization procedure and spontaneous balloon deflation with subsequent reflux in one in vivo embolization procedure. CONCLUSION: Extra-small dual-lumen micro-balloon catheters can improve endovascular embolization in comparison with standard microcatheter embolization.