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İNFRATROKLEAR VE SUPRATROKLEAR ÜÇGENLERİN VARYATİF ANATOMİSİ VE MİKRONÖROCERRAHİ ÖNEMİ

Year 2020, Volume: 83 Issue: 4, 355 - 362, 19.10.2020

Abstract

Amaç: Supratroklear ve infratroklear üçgenler, sinus cavernosus’un lateral duvarına ulaşmak için kullanılabilecek cerrahi koridorlardır. Literatürde bu üçgenlerin morfolojisi ve morfometrisi hakkında çelişkili bilgiler bulunmaktadır. Ayrıca, sinus cavernosus’a drene olan vasküler yapıların anatomiye olan etkileri bilinmemektedir. Bu çalışma sinus cavernosus üçgenlerinde olan supratroklear ve infratroklear üçgenlerin morfolojisini, morfometrisini ve vasküler komşuluklarını incelemeyi amaçlamıştır. Gereç ve Yöntem: Yirmibeş kadavranın kafa tabanı cerrahi mikroskop altında bilateral olarak disseke edildi. Vasküler yapıların değerlendirilmesi amacıyla 5 kadavrada renkli silikon enjeksiyonu yapıldı. Supratroklear ve infratroklear üçgen morfolojisi, n. trochlearis’in uzanımına göre sınıflandırıldı. Her iki üçgenin alanları, ImageJ yazılımı kullanılarak fotogrametrik yöntem ile ölçüldü. Üçgenlerin morfolojisi ile v. cerebri media superficialis ve kafa tabanı dural sinüslerinin drenaj paterni karşılaştırıldı. Bulgular: Tip A, B, C ve D üçgen morfolojisi sırasıyla 23 (%46), 9 (%18), 10 (%20) ve 8 (%16) tarafta gözlemlendi. Supratroklear ve infratroklear üçgenlerin ortalama alanları 22,2 (±11,7) mm2 ve 78,4 (±27,7) mm2 ölçüldü. Tip D üçgenlerde supratroklear üçgenin daha büyük olduğu görüldü. İnjeksiyon yapılan örneklerin %71,4’ünde sinus petrosus superior, sinus cavernosus’a drene olmakta ve belirgin Tip A üçgen meydana getirmekteydi. Sonuç: Supratroklear ve infratroklear üçgenler, literatürde raporlandığının aksine çok varyatifti. Bu çeşitlilik bilgisinin beyin cerrahisi uzmanlık eğitimi ve günlük cerrahi uygulamaya aktarılması düşünülebilir.

Supporting Institution

İstanbul Üniversitesi Bilimsel Araştırma Projeleri Koordinasyon Birimi

Project Number

TSA-2016-20144

References

  • 1. Dolenc V. Direct microsurgical repair of intracavernous vascular lesions. J Neurosurg 1983;58(6):824-31. [CrossRef]
  • 2. Isolan GR, Krayenbühl N, de Oliviera E, Al-Mefty O. Microsurgical anatomy of the cavernous sinus: measurements of the triangles in and around it. Skull Base 2007;17(6):357-67. [CrossRef]
  • 3. Parkinson D. A surgical approach to the cavernous portion of the carotid artery: anatomical studies and case report. J Neurosurg 1965;23(5):474-83. [CrossRef]
  • 4. Parkinson D. Transcavernous repair of carotid cavernous fistula. J Neurosurg 1967;26(4):420-4. [CrossRef]
  • 5. Rhoton ALjr: The middle cranial base and cavernous sinus. In Dolenc VV, Rogers L (eds), Cavernous Sinus: Developments and Future Perspectives. Wien, Springer Verlag, 2009;3-25. [CrossRef]
  • 6. Romero FR, Ramires D, Cristiano LC, Silva MP, Vieira RB. Endoscopic and microsurgical approaches to the cavernous sinus - Anatomical review. Arq Bras Neurocir 2017;36(3):160- 6. [CrossRef]
  • 7. Harris FS, Rhoton ALjr. Anatomy of the cavernous sinus: a microsurgical study. J Neurosurg 1976;45(2):169-80. [CrossRef]
  • 8. Inoue T, Rhoton ALjr, Theele D, Barry ME. Surgical approaches to the cavernous sinus: a microsugical study. Neurosurgery 1990;26(6):903-932. [CrossRef]
  • 9. Kayalioglu G, Govsa F, Erturk M, Pinar Y, Ozer MA, Ozgur T. The cavernous sinus: topographic morphometry of its contents. Surg Radiol Anat 1999;21(4):255-60. [CrossRef]
  • 10. Lang J, Reiter U. Über den verlauf der hirnnerven in der seitenwand des sinus cavernosus. Neurochirurgia 1984;27(4):93-7. [CrossRef]
  • 11. Miyazaki Y, Yamamoto I, Shinozuka T, Sato O. Microsurgical anatomy of the cavernous sinus. Neurol Med Chir 1994;34(3):150-63. [CrossRef]
  • 12. Sekhar LN, Burges J, Akın O. Anatomical study of the cavernous sinus emphasizing operative approaches and related vascular and neural reconstruction. Neurosurgery 1987;21(6):806-16. [CrossRef]
  • 13. Watanabe A, Nagaseki Y, Ohkubo S, Ohhashi Y, Horikoshi T, Nishigaya K et al. Anatomical variations of the ten triangles around the cavernous sinus. Clin Anat 2003;16(1):9-14. [CrossRef]
  • 14. Keller JT, Leach JL, van Loveren HR, Abdel Aziz KM, Froelich S: Venous anatomy of the lateral sellar compartment. In Dolenc VV, Rogers L (eds), Cavernous Sinus: Developments and Future Perspectives. Wien, Springer Verlag, 2009;35-51. [CrossRef]
  • 15. Suzuki Y, Matsumoto K. Variations of the superficial middle cerebral vein: Classification using three-dimensional CT angiography. Am J Neuroradiol 2000;21(5):932-8.
  • 16. Gürses İA, Coşkun O, Öztürk A. Current status of cadaver sources in Turkey and a wake-up call for Turkish Anatomists. Anat Sci Educ 2018;11(2):155-65. [CrossRef]
  • 17. Sanan A, Abdel Aziz KM, Janjua RM, van Loveren HR, Keller JT. Colored silicone injection for use in neurosurgical dissections: Anatomic technical note. Neurosurgery 1999;45(5):1267-71.
  • 18. Rasband WS. ImageJ, U.S. National Institutes of Health, Bethesda, Maryland, USA, 1997-2016 https://imagej.nih. gov/ij/ [accessed 21 September 2019]
  • 19. Dalgıç A, Boyacı S, Aksoy K. Anatomical study of the cavernous sinus emphasizing operative approaches. Turk Neurosurg 2010;20(2):186-204. [CrossRef]
  • 20. Chotai S, Liu Y, Qi S. Review of surgical anatomy of the tumors involving cavernous sinus. Asian J Neurosurg 2018;13(1):1-8. [CrossRef]
  • 21. Heth JA, Al-Mefty O. Cavernous sinus meningiomas. Neurosurg Focus 2003;14(6):e3. [CrossRef] 22. Komatsu F, Komatsu M, Inoue T, Tschabitscher M. Endoscopic supraorbital extradural approach to the cavernous sinus: A cadaver study. J Neurosurg 2011;114(5):1331-7.
  • 23. Knosp E, Perneczky A, Koos WT, Fries G, Matula C. Meningiomas of the space of the cavernous sinus. Neurosurg 1996;38(3):434-44. [CrossRef]
  • 24. Sun DQ, Menezes AH, Howard MA, Gantz BJ, Hasan DM, Hansen MR. Surgical management of tumors involving Meckel’s cave and cavernous sinus: Role of an extended middle fossa and lateral sphenoidectomy approach. Otol Neurotol 2018;39(1):82-91.
  • 25. Dolci RLL, Upadhyay S, Filho LFSD, Fiore ME, Buohliqah L, Lazarini PR et al. Endoscopic endonasal study of the cavernous sinüs and quadrangular space: Anatomic relationships. Head Neck 2016;38(Suppl-1):E1680-7.
  • 26. Koutourousiou M, Filho FVG, Fernandez-Miranda JC, Wang EW, Stefko ST, Snyderman CH et al. Endoscopic endonasal surgery for tumors of the cavernous sinus: A series of 234 patients. World Neurosurg 2017;103:713-32.
  • 27. Theodosopoulos PV, Cebula H, Kurbanov A, Cabero AB, Osorio JA, Zimmer LA et al. The medial extra-sellar corridor to the cavernous sinus: Anatomic description and clinical correlation. World Neurosurg 2016;96:417-22.
  • 28. Woodworth GF, Patel KS, Shin B, Burkhardt JK, Tsiouris AJ, McCoul ED et al. Surgical outcomes using a medialto- lateral endonasal endoscopic approach to pituitary adenomas invading the cavernous sinus. J Neurosurg 2014;120(5):1086-94.
  • 29. Day JD, Tschabitscher M: Microsurgical dissection of the cranial base. Churchill Livingstone, New York, 1996.
  • 30. Samii M, Gerganov VM: Surgery of cavernous sinus meningiomas: Advantages and disadvantages. In Dolenc VV, Rogers L (eds), Cavernous Sinus: Developments and Future Perspectives. Wien, Springer Verlag, 2009;153-62.
  • 31. Tanoue S, Kiyosue H, Okahara M, Sagara Y, Hori Y, Kashiwagi J et al. Para-cavernous sinus venous structures: Anatomic variations and pathologic conditions evaluated on fat-suppressed 3D fast gradient-echo MR images. Am J Neuroradiol 2006;27(5):1083-89.
  • 32. Chung BS, Ahn YH, Park JS. Ten triangles around cavernous sinus for surgical approach, described by schematic diagram and three dimensional models with the sectioned images. J Korean Med Sci 2016;31(9):1455-63.
  • 33. Park JS, Chung MS, Shin DS, Har DH, Cho ZH, Kim YB et al. Sectioned images of the cadaver head including the brain and correspondences with ultrahigh field 7 T MRIs. Proc IEEE 2009;97(12):1988-96.
  • 34. Park HS, Chung MS, Shin DS, Jung YW, Park JS. Whole courses of the oculomotor, trochlear, and abducens nerves, identified in sectioned images and surface models. Anat Rec 2015;298(2):436-43. 35. Hakuba A, Tanaka K, Suzuki T, Nishimura S. A combined orbitozygomatic infratemporal epidural and subdural approach for lesions involving the entire cavernous sinus. J Neurosurg 1989;71(5Pt1):699-704.
  • 36. Qian ZH, Feng X, Li Y, Tand K. Virtual reality model of the three-dimentional anatomy of the cavernous sinus based on a cadaveric image and dissection. J Craniofac Surg 2018;29(1):163-6.

VARIABLE ANATOMY OF THE INFRATROCHLEAR AND SUPRATROCHLEAR TRIANGLES AND THEIR MICRONEUROSURGICAL IMPORTANCE

Year 2020, Volume: 83 Issue: 4, 355 - 362, 19.10.2020

Abstract

Objective: Supratrochlear and infratrochlear triangles are surgical corridors for approaching the lateral wall of the cavernous sinus. The literature provides conflicting results for the morphology and morphometry of these triangles. Additionally, the possible effects of vascular structures that drain into the cavernous sinus in unknown. This study aimed to investigate the morphology, morphometry, and vascular relationships of the supratrochlear and infratrochlear triangles of the cavernous sinus. Material and Method: Cranial bases of 25 cadavers were dissected bilaterally under a surgical microscope. Five of the cadavers were injected with colored silicone for vascular evaluation. The morphology of supratrochlear and infratrochlear triangles were classified according to the course of the trochlear nerve. Photogrametric measurements were used for evaluating the areas of both triangles with the ImageJ software. The triangular morphology was also investigated in regard to the drainage patterns of the superficial middle cerebral vein and cranial base dural sinuses. Results: Type A, B, C, and D triangle morphology was present on 23 (46%), 9 (18%), 10 (20%), and 8 (16%) sides, respectively. The average areas for supratrochlear and infratrochlear triangles were 22.2 (±11.7) mm2 and 78.4 (±27.7) mm2, respectively. The supratrochlear triangle was significantly larger in Type D triangles. On 71.4% of injected specimens, the superior petrosal sinus contributed the cavernous sinus and formed a Type A triangle. Conclusion: The anatomy of the supratrochlear and infratrochlear triangles are highly variable than previously reported. Introducing the knowledge regarding these variations to neurosurgical residency education programs and daily surgical practice could be valuable.

Project Number

TSA-2016-20144

References

  • 1. Dolenc V. Direct microsurgical repair of intracavernous vascular lesions. J Neurosurg 1983;58(6):824-31. [CrossRef]
  • 2. Isolan GR, Krayenbühl N, de Oliviera E, Al-Mefty O. Microsurgical anatomy of the cavernous sinus: measurements of the triangles in and around it. Skull Base 2007;17(6):357-67. [CrossRef]
  • 3. Parkinson D. A surgical approach to the cavernous portion of the carotid artery: anatomical studies and case report. J Neurosurg 1965;23(5):474-83. [CrossRef]
  • 4. Parkinson D. Transcavernous repair of carotid cavernous fistula. J Neurosurg 1967;26(4):420-4. [CrossRef]
  • 5. Rhoton ALjr: The middle cranial base and cavernous sinus. In Dolenc VV, Rogers L (eds), Cavernous Sinus: Developments and Future Perspectives. Wien, Springer Verlag, 2009;3-25. [CrossRef]
  • 6. Romero FR, Ramires D, Cristiano LC, Silva MP, Vieira RB. Endoscopic and microsurgical approaches to the cavernous sinus - Anatomical review. Arq Bras Neurocir 2017;36(3):160- 6. [CrossRef]
  • 7. Harris FS, Rhoton ALjr. Anatomy of the cavernous sinus: a microsurgical study. J Neurosurg 1976;45(2):169-80. [CrossRef]
  • 8. Inoue T, Rhoton ALjr, Theele D, Barry ME. Surgical approaches to the cavernous sinus: a microsugical study. Neurosurgery 1990;26(6):903-932. [CrossRef]
  • 9. Kayalioglu G, Govsa F, Erturk M, Pinar Y, Ozer MA, Ozgur T. The cavernous sinus: topographic morphometry of its contents. Surg Radiol Anat 1999;21(4):255-60. [CrossRef]
  • 10. Lang J, Reiter U. Über den verlauf der hirnnerven in der seitenwand des sinus cavernosus. Neurochirurgia 1984;27(4):93-7. [CrossRef]
  • 11. Miyazaki Y, Yamamoto I, Shinozuka T, Sato O. Microsurgical anatomy of the cavernous sinus. Neurol Med Chir 1994;34(3):150-63. [CrossRef]
  • 12. Sekhar LN, Burges J, Akın O. Anatomical study of the cavernous sinus emphasizing operative approaches and related vascular and neural reconstruction. Neurosurgery 1987;21(6):806-16. [CrossRef]
  • 13. Watanabe A, Nagaseki Y, Ohkubo S, Ohhashi Y, Horikoshi T, Nishigaya K et al. Anatomical variations of the ten triangles around the cavernous sinus. Clin Anat 2003;16(1):9-14. [CrossRef]
  • 14. Keller JT, Leach JL, van Loveren HR, Abdel Aziz KM, Froelich S: Venous anatomy of the lateral sellar compartment. In Dolenc VV, Rogers L (eds), Cavernous Sinus: Developments and Future Perspectives. Wien, Springer Verlag, 2009;35-51. [CrossRef]
  • 15. Suzuki Y, Matsumoto K. Variations of the superficial middle cerebral vein: Classification using three-dimensional CT angiography. Am J Neuroradiol 2000;21(5):932-8.
  • 16. Gürses İA, Coşkun O, Öztürk A. Current status of cadaver sources in Turkey and a wake-up call for Turkish Anatomists. Anat Sci Educ 2018;11(2):155-65. [CrossRef]
  • 17. Sanan A, Abdel Aziz KM, Janjua RM, van Loveren HR, Keller JT. Colored silicone injection for use in neurosurgical dissections: Anatomic technical note. Neurosurgery 1999;45(5):1267-71.
  • 18. Rasband WS. ImageJ, U.S. National Institutes of Health, Bethesda, Maryland, USA, 1997-2016 https://imagej.nih. gov/ij/ [accessed 21 September 2019]
  • 19. Dalgıç A, Boyacı S, Aksoy K. Anatomical study of the cavernous sinus emphasizing operative approaches. Turk Neurosurg 2010;20(2):186-204. [CrossRef]
  • 20. Chotai S, Liu Y, Qi S. Review of surgical anatomy of the tumors involving cavernous sinus. Asian J Neurosurg 2018;13(1):1-8. [CrossRef]
  • 21. Heth JA, Al-Mefty O. Cavernous sinus meningiomas. Neurosurg Focus 2003;14(6):e3. [CrossRef] 22. Komatsu F, Komatsu M, Inoue T, Tschabitscher M. Endoscopic supraorbital extradural approach to the cavernous sinus: A cadaver study. J Neurosurg 2011;114(5):1331-7.
  • 23. Knosp E, Perneczky A, Koos WT, Fries G, Matula C. Meningiomas of the space of the cavernous sinus. Neurosurg 1996;38(3):434-44. [CrossRef]
  • 24. Sun DQ, Menezes AH, Howard MA, Gantz BJ, Hasan DM, Hansen MR. Surgical management of tumors involving Meckel’s cave and cavernous sinus: Role of an extended middle fossa and lateral sphenoidectomy approach. Otol Neurotol 2018;39(1):82-91.
  • 25. Dolci RLL, Upadhyay S, Filho LFSD, Fiore ME, Buohliqah L, Lazarini PR et al. Endoscopic endonasal study of the cavernous sinüs and quadrangular space: Anatomic relationships. Head Neck 2016;38(Suppl-1):E1680-7.
  • 26. Koutourousiou M, Filho FVG, Fernandez-Miranda JC, Wang EW, Stefko ST, Snyderman CH et al. Endoscopic endonasal surgery for tumors of the cavernous sinus: A series of 234 patients. World Neurosurg 2017;103:713-32.
  • 27. Theodosopoulos PV, Cebula H, Kurbanov A, Cabero AB, Osorio JA, Zimmer LA et al. The medial extra-sellar corridor to the cavernous sinus: Anatomic description and clinical correlation. World Neurosurg 2016;96:417-22.
  • 28. Woodworth GF, Patel KS, Shin B, Burkhardt JK, Tsiouris AJ, McCoul ED et al. Surgical outcomes using a medialto- lateral endonasal endoscopic approach to pituitary adenomas invading the cavernous sinus. J Neurosurg 2014;120(5):1086-94.
  • 29. Day JD, Tschabitscher M: Microsurgical dissection of the cranial base. Churchill Livingstone, New York, 1996.
  • 30. Samii M, Gerganov VM: Surgery of cavernous sinus meningiomas: Advantages and disadvantages. In Dolenc VV, Rogers L (eds), Cavernous Sinus: Developments and Future Perspectives. Wien, Springer Verlag, 2009;153-62.
  • 31. Tanoue S, Kiyosue H, Okahara M, Sagara Y, Hori Y, Kashiwagi J et al. Para-cavernous sinus venous structures: Anatomic variations and pathologic conditions evaluated on fat-suppressed 3D fast gradient-echo MR images. Am J Neuroradiol 2006;27(5):1083-89.
  • 32. Chung BS, Ahn YH, Park JS. Ten triangles around cavernous sinus for surgical approach, described by schematic diagram and three dimensional models with the sectioned images. J Korean Med Sci 2016;31(9):1455-63.
  • 33. Park JS, Chung MS, Shin DS, Har DH, Cho ZH, Kim YB et al. Sectioned images of the cadaver head including the brain and correspondences with ultrahigh field 7 T MRIs. Proc IEEE 2009;97(12):1988-96.
  • 34. Park HS, Chung MS, Shin DS, Jung YW, Park JS. Whole courses of the oculomotor, trochlear, and abducens nerves, identified in sectioned images and surface models. Anat Rec 2015;298(2):436-43. 35. Hakuba A, Tanaka K, Suzuki T, Nishimura S. A combined orbitozygomatic infratemporal epidural and subdural approach for lesions involving the entire cavernous sinus. J Neurosurg 1989;71(5Pt1):699-704.
  • 36. Qian ZH, Feng X, Li Y, Tand K. Virtual reality model of the three-dimentional anatomy of the cavernous sinus based on a cadaveric image and dissection. J Craniofac Surg 2018;29(1):163-6.
There are 34 citations in total.

Details

Primary Language English
Subjects Health Care Administration
Journal Section RESEARCH
Authors

İlke Ali Gürses 0000-0001-9188-4662

Osman Coşkun This is me 0000-0002-0337-4927

Özcan Gayretli This is me 0000-0001-7958-3170

Ayşin Kale This is me 0000-0002-2305-420X

Adnan Öztürk This is me 0000-0002-5819-0543

Project Number TSA-2016-20144
Publication Date October 19, 2020
Submission Date September 27, 2019
Published in Issue Year 2020 Volume: 83 Issue: 4

Cite

APA Gürses, İ. A., Coşkun, O., Gayretli, Ö., Kale, A., et al. (2020). VARIABLE ANATOMY OF THE INFRATROCHLEAR AND SUPRATROCHLEAR TRIANGLES AND THEIR MICRONEUROSURGICAL IMPORTANCE. Journal of Istanbul Faculty of Medicine, 83(4), 355-362.
AMA Gürses İA, Coşkun O, Gayretli Ö, Kale A, Öztürk A. VARIABLE ANATOMY OF THE INFRATROCHLEAR AND SUPRATROCHLEAR TRIANGLES AND THEIR MICRONEUROSURGICAL IMPORTANCE. İst Tıp Fak Derg. October 2020;83(4):355-362.
Chicago Gürses, İlke Ali, Osman Coşkun, Özcan Gayretli, Ayşin Kale, and Adnan Öztürk. “VARIABLE ANATOMY OF THE INFRATROCHLEAR AND SUPRATROCHLEAR TRIANGLES AND THEIR MICRONEUROSURGICAL IMPORTANCE”. Journal of Istanbul Faculty of Medicine 83, no. 4 (October 2020): 355-62.
EndNote Gürses İA, Coşkun O, Gayretli Ö, Kale A, Öztürk A (October 1, 2020) VARIABLE ANATOMY OF THE INFRATROCHLEAR AND SUPRATROCHLEAR TRIANGLES AND THEIR MICRONEUROSURGICAL IMPORTANCE. Journal of Istanbul Faculty of Medicine 83 4 355–362.
IEEE İ. A. Gürses, O. Coşkun, Ö. Gayretli, A. Kale, and A. Öztürk, “VARIABLE ANATOMY OF THE INFRATROCHLEAR AND SUPRATROCHLEAR TRIANGLES AND THEIR MICRONEUROSURGICAL IMPORTANCE”, İst Tıp Fak Derg, vol. 83, no. 4, pp. 355–362, 2020.
ISNAD Gürses, İlke Ali et al. “VARIABLE ANATOMY OF THE INFRATROCHLEAR AND SUPRATROCHLEAR TRIANGLES AND THEIR MICRONEUROSURGICAL IMPORTANCE”. Journal of Istanbul Faculty of Medicine 83/4 (October 2020), 355-362.
JAMA Gürses İA, Coşkun O, Gayretli Ö, Kale A, Öztürk A. VARIABLE ANATOMY OF THE INFRATROCHLEAR AND SUPRATROCHLEAR TRIANGLES AND THEIR MICRONEUROSURGICAL IMPORTANCE. İst Tıp Fak Derg. 2020;83:355–362.
MLA Gürses, İlke Ali et al. “VARIABLE ANATOMY OF THE INFRATROCHLEAR AND SUPRATROCHLEAR TRIANGLES AND THEIR MICRONEUROSURGICAL IMPORTANCE”. Journal of Istanbul Faculty of Medicine, vol. 83, no. 4, 2020, pp. 355-62.
Vancouver Gürses İA, Coşkun O, Gayretli Ö, Kale A, Öztürk A. VARIABLE ANATOMY OF THE INFRATROCHLEAR AND SUPRATROCHLEAR TRIANGLES AND THEIR MICRONEUROSURGICAL IMPORTANCE. İst Tıp Fak Derg. 2020;83(4):355-62.

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