Percutaneous approach to the foramen ovale: an anatomical study of the extracranial trajectory with the incorrect trajectories to be avoided.
OBJECTIVE
Meckel's Cave may be accessed percutaneously through the foramen ovale (FO). Detailed knowledge of the region's anatomical surroundings is invaluable in improving target accuracy and preventing complications with this approach. The approach has been used in the treatment of trigeminal neuralgia as well as in performing biopsies of lesions located in the parasellar region, described formerly by the senior author (M.S.). A comprehensive cadaveric study of the region traversed by needle is thus presented.


METHODS
Three cadaveric heads (six sides) were fixed in formaldehyde and injected with latex. A detailed description of the regional anatomical needle trajectories was performed.


RESULTS
An "inverted pyramid" subdivided into three segments is described. The inferior third begins at cutaneous penetration and ends at the parotid duct (PD). The middle third extends from the PD to the lateral pterygoid muscle (LPM). The superior third starts from the LPM and ends at the FO. The main vascular anatomical variation was with regard to the maxillary artery (MA). In half of the cases, the MA traveled though the middle of the pyramid and in the other half through the upper third.


CONCLUSIONS
Although widely used, the FO approach carries risks. Special attention is warranted when the needle traverses the upper third of the pyramid to avoid the variant course of the MA. Image-guided techniques and detailed anatomical knowledge are necessary to expand the use of this route not just for approach to lesions within the parasellar and upper third of the petroclival region but also to lesions invading the infratemporal fossa.
Department of Neurosurgery, Tulane University Microsurgical Laboratory, New Orleans, LA, USA. jalvernia@yahoo.com
Jorge E
JE
Alvernia
Marc P
MP
Sindou
Nguyen D
ND
Dang
Jason H
JH
Maley
Patrick
P
Mertens
D001158:Arteries / Q000473:pathology / Q000601:surgery; D003399:Craniotomy / Q000379:methods*; D004210:Dissection / Q000379:methods*; D005145:Face / Q000098:blood supply; D005154:Facial Nerve / Q000473:pathology / Q000601:surgery; D006801:Humans; D008340:Mandibular Nerve / Q000473:pathology / Q000601:surgery; D008406:Masseter Muscle / Q000473:pathology / Q000601:surgery; D008866:Microsurgery / Q000379:methods*; D010306:Parotid Gland / Q000473:pathology / Q000601:surgery; D011626:Pterygoid Muscles / Q000473:pathology / Q000601:surgery; D018987:Salivary Ducts / Q000473:pathology / Q000601:surgery; D013100:Sphenoid Bone / Q000473:pathology / Q000601:surgery; D013703:Temporal Muscle / Q000473:pathology / Q000601:surgery; D014276:Trigeminal Nerve / Q000473:pathology / Q000601:surgery; D014277:Trigeminal Neuralgia / Q000473:pathology* / Q000601:surgery*; D014680:Veins / Q000473:pathology / Q000601:surgery; D015050:Zygoma / Q000473:pathology / Q000601:surgery*