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JUN LIU ET AL. THREE-DIMENSIONAL RECONSTRUCTION IN THE SELLAR REGION

9. Qiu MG, Zhang SX, Liu ZJ, Tan LW, Wang YS, Deng JH,Tang ZS: Three-dimensional computational reconstruc-tion of lateral skull base with plastinated slices. Anat RecA Discov Mol Cell Evol Biol 278:437-442, 2004.

0. Rhoton AL Jr: The cavernous sinus, the cavernousvenous plexus, and the carotid collar. Neurosurgery51:375-410, 2002.

1. Rhoton AL Jr: The sellar region. Neurosurgery 51:335-374, 2002.

2. Spitzer VM, Ackerman MJ, Scherzinger AL, Whit-lock D: The visible human male: a technical report. JAm Med Inform Assoc 3:118-130, 1996.

3. Sun B, Tang YC, Fan LZ, Lin XT, Qi HT, Liu SW: Thepineal region: thin sectional anatomy with MR cor-

relation in the coronal plane. Surg Radiol Anat 30:575-582, 2008.

R. Shane Tubbs1, Martin M. Mortazavi1,

gopalatine ganglion. These latter fibers,

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WORLD NEUROSURGERY 78 [5]: 515-518

4. Tang YC, Zhao ZM, Lin XT, Sun B, Fan LZ, Hou ZY,Qi HT, Li ZP, Liu SW: The thin sectional anatomy ofthe sellar region with MRI correlation. Surg RadiolAnat 32:573-580, 2010.

5. Tan HKK, Ong YK: Sphenoid sinus: an anatomicand endoscopic study in Asian cadavers. Clin Anat20:745-750, 2007.

6. Unlu A, Meco C, Ugur HC, Comert A, Ozdemir M,Elhan A: Endoscopic anatomy of sphenoid sinus forpituitary surgery. Clin Anat 21:627-632, 2008.

7. Weninger WJ, Prokop M: In vivo 3D analysis of the adi-pose tissue in the orbital apex and the compartments ofthe parasellar region. Clin Anat 17:112-117, 2004.

8. Yasuda A, Campero A, Martins C, Rhoton AL Jr, Ribas

GC: The media wall of the cavernous sinus: microsur-gical anatomy. Neurosurgery 55:179-190, 2004.

Mohammadali M. Shoja2, Marios Loukas

raorbital sulcus) branches into the zygo-

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9. Yilmaziar S, Kocaeli H, Aydiner F, Korfali E: Medialportion of the cavernous sinus: quantitative analysis ofthe medial wall. Clin Anat 18:416-422, 2005.

onflict of interest statement: This work was supported byational Natural Science Foundation of China (NSFC, No.0871305).

eceived 09 May 2011; accepted 02 December 2011;ublished online 10 December 2011

itation: World Neurosurg. (2012) 78, 5:510-515.OI: 10.1016/j.wneu.2011.12.005

ournal homepage: www.WORLDNEUROSURGERY.org

vailable online: www.sciencedirect.com

878-8750/$ - see front matter © 2012 Elsevier Inc.ll rights reserved.

The Zygomaticotemporal Nerve and Its Relevance to Neurosurgery

3, Aaron A. Cohen-Gadol4

INTRODUCTION

The zygomatic nerve, a branch of the max-illary division of the trigeminal nerve, arisesin the pterygopalatine fossa. This nerve car-ries cutaneous fibers and postsynaptic para-sympathetic fibers arising from the ptery-

Key words� Anatomy� Craniotomy� Entrapment� Neurosurgery� Peripheral nerve

Abbreviations and AcronymsZTN: Zygomaticotemporal nerve

From the 1Section ofPediatric Neurosurgery,

Children’s Hospital, Birmingham, Alabama, USA;2Neuroscience Research Center, Tabriz University of Medical

ciences, Tabriz, Iran; 3Department of Anatomical Sciences,t. George’s University, Grenada, West Indies; 4Goodman

Campbell Brain and Spine, Indiana University Department ofNeurological Surgery, Indianapolis, Indiana, USA

To whom correspondence should be addressed:Aaron A. Cohen-Gadol, M.D., M.Sc.[E-mail: acohenmd@gmail.com]

Citation: World Neurosurg. (2012) 78, 5:515-518.DOI: 10.1016/j.wneu.2011.09.028

Journal homepage: www.WORLDNEUROSURGERY.org

Available online: www.sciencedirect.com

1878-8750/$ - see front matter © 2012 Elsevier Inc.All rights reserved.

riginating from the superior salivatory nu-leus and passing through the greateretrosal branch of the facial nerve, termi-ate on the lacrimal gland. The zygomaticerve enters the orbit via the inferior orbitalssure and along the floor of the orbit (in-

� BACKGROUND: Although neurosurin its territory, the zygomaticotemporaliterature, even though this nerve hasyndromes and may become entrapppresent study was performed to furthe

� METHODS: Twelve cadavers (24 stemporal region to analyze the course,

� RESULTS: A ZTN was found on allzygoma to enter the temporal fossamuscle or between this muscle andnear the pterion. Fascial or muscle psuperior to the zygomatic arch. The mapproximately parallel to the frontopdistance from the ZTN to the frontozyg

� CONCLUSIONS: Based on our studytakes it along a superficial pathway ova greater appreciation for its anatomprovided herein, that injury to the ZTNin its territory, and if entrapped, may

aticofacial nerve and the zygomaticotem-oral nerve (ZTN) with an angle ofpproximately 20° to 40° between themFigure 1) (4, 7). In the lateral orbit, a com-

unicating branch from the lacrimal nerveoins the ZTN. The ZTN then passes

procedures are frequently performedrve (ZTN) is rarely mentioned in thiseen implicated in postsurgical painresulting in chronic headache. Thecidate the anatomy of the ZTN.

underwent dissection of the lateraltionships, and landmarks for the ZTN.

1 left side. This nerve left the lateralascended up through the temporalisuter fascia to become subcutaneousration occurred at a mean of 2.3 cmty of nerves then coursed posteriorly,tal suture of the pterion. The meantic suture was 12 mm.

ZTN has a fairly standard course thatng the pterion. It is our hope that withnd landmarks for its localization asbe avoided with surgical proceduresore easily identified by the surgeon.

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w.WORLDNEUROSURGERY.org 515

matic nerve (Z).

PEER-REVIEW REPORTS

R. SHANE TUBBS ET AL. ZYGOMATICOTEMPORAL NERVE

located on the temporal surface of the zygo-matic bone to enter the temporal fossa (10).

Although neurosurgical procedures arefrequently performed in its territory, the ZTNis rarely mentioned in the neurosurgical liter-ature, and only a handful of studies are foundin the general medical literature regarding itsanatomy. Because this nerve may become en-trapped, resulting in protracted pain in thetemporal region, or injured with neurosurgi-cal procedures (3, 12), the present study wasperformed to further elucidate its anatomy.

MATERIALS AND METHODS

Twelve cadaveric heads (24 sides) under-went dissection of the lateral temporal re-gion to analyze the course, relationships,and landmarks for the ZTN. Ten fresh and 2embalmed adult cadavers underwent dis-section of the lateral temporal region. Eightspecimens were male, and 4 were female;the age range at death was from 55 to 101years (mean 74.5 years). In the supine posi-tion and in the lateral position, the skin andsuperficial fascia were carefully reflected.Terminal branches of the ZTN were identi-fied and traced deeply through the tempora-lis fascia and muscle to the zygomaticotem-poral foramen. Measurements were madeof the diameter of the ZTN and its distanceposterior to the frontozygomatic suture.Documentation of the relationship between

Figure 1. Schematic drawing of theanterior view noting its relationshmain trunk of this nerve, the zygo

the ZTN and surrounding anatomical struc-zygoma (marked Z).

516 www.SCIENCEDIRECT.com WORLD NEUROSURGE

tures, including the temporalis muscle andauriculotemporal and lacrimal nerves, wasmade. All measurements were made withdigital calipers (Mitutoyo, Kanagawa, Ja-pan). Statistical analysis was performed be-tween cadavers and genders using Statisticafor Windows (Tulsa, Oklahoma, USA) withsignificance set at P � 0.05.

RESULTS

A ZTN was found on all but 1 left side (4.2%)on a female cadaver. This nerve left the tem-poral surface of the zygomatic bone via thezygomaticotemporal foramen and as-cended more or less vertically up throughthe temporalis muscle or between this mus-cle and its outer fascia to become subcuta-neous over the pterion (Figure 2A). The ma-jority of nerves, which were always a singletrunk, then coursed posteriorly, approxi-mately parallel to the frontoparietal sutureof the pterion. In its ascent between the bone

ft zygomaticotemporal nerve (ZTN) (over theThe frontozygomatic suture (FZS) is seen atain trunk of the ZTN in this region and the FZSer opening of the temporal fascia. The left ZTNe FZS is marked with black ink. The distancessuture and zygomatic arch are shown. (C)

mporalis muscle demonstrating the exit of theior to the FZS. For reference, note the left

zygomaticotemporal nerve from anips to the lateral orbital wall. Note the

Figure 2. (A) Cadaveric dissection demonstrating the leblue card) at its emergence from the temporal fascia.the black dot. The distance measured between the mis shown as the yellow line. (B) Cadaver seen in A aftand its branches are seen overlying the blue cards. Thmeasured between the main trunk of the ZTN and theLeft-sided cadaveric dissection after removal of the teZTN leaving its foramen and ascending up and poster

RY, DOI:10.1016/j.wneu.2011.09.028

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R. SHANE TUBBS ET AL. ZYGOMATICOTEMPORAL NERVE

and the temporalis muscle, the ZTN piercedthe superficial temporal fascia on average 2.3cm (range 1.9 to 2.6 cm) superior to the zygo-matic arch. Cutaneously, the ZTN was pri-marily distributed to the skin of the anteriortemporal region (Figure 2B). The superiortemporal line was the most superior extent ofany ZTN distal fibers. The ZTN was found tohave 1 to 3 terminal branches (mean 1.8) (Fig-ure 2B). The mean diameter of the ZTN was0.9 mm, with a range of 0.8 to 1.1 mm. Themean distance from the ZTN to the frontozy-gomatic suture was 12 mm (range 8 to 15 mm)(Figure 2C). The ZTN was found to communi-ate with the posteriorly located auriculotem-oral branch of the mandibular nerve on 3ides (13%) and anteriorly with the lacrimalerve (branch of the ophthalmic nerve) on 2ides (8.7%). Connections with the auriculo-emporal and lacrimal nerves were approxi-

ately horizontal. We did not find any com-unications between the ZTN and the

emporal branch of the facial nerve in anypecimen (13). No signs of past surgery orathology were identified in the area of dis-ection in any specimen. No statistical differ-nce was noted between genders or sides.

ISCUSSION

eurosurgical procedures, such as cranioto-ies, often result in persistent headache thatay be due to neurovascular compromise,

erve traction during surgical procedures, orompression of the nerve by scar tissue (3, 12).amage to sensory nerves of the head may

lso lead to temporary or permanent loss ofensation (1). Muscular, vascular, and fascialntrapments of peripheral branches of the tri-eminal nerve, including the ZTN, have beeneported as trigger points for migraine head-ches (5, 13). Interestingly, surgical decom-ression of such nerves has led to completeesolution of symptoms in some patients (11).

Specifically, the ZTN has been shown clini-cally to have sites of entrapment within thetemporalis (13) and surgical decompressionor chemical denervation of the surroundingtemporalis muscle may improve migraineheadache symptoms (5, 13). Some have foundgood results with avulsion of the ZTN in somepatients with migraine headaches, and re-ported that second to the supraorbital and su-pratrochlear nerves, this nerve is the most com-mon trigger site for such headaches (6).

Anatomically, Janis et al. (8) found in 25

specimens that the ZTN had no intramuscular w

WORLD NEUROSURGERY 78 [5]: 515-518

ourse. In 11 specimens, the nerve had a briefntramuscular course, and in 14 specimens, itad a long, tortuous, muscular pathway. To-

onchi et al. (13) found that the main trunk ofhe ZTN emerged from the deep temporal fas-ia on average 17 mm lateral and 6 mm cranialo the lateral canthus. Jeong et al. (9) foundhat the ZTN was on average 22 mm superioro the upper margin of the zygomatic arch andlassified this nerve into 3 types. The type Ierve seen in 73% consisted of 2 branches.ypes II (20%) and III (7%) had 3 and 0ranches, respectively. Hwang et al. (7) found

hat the ZTN traveled posterior to the greatering of the sphenoid in a third of their speci-ens. We found a ZTN on 95.8% of sides and

ound that it pierced the superficial temporalascia, on average, 2.3 cm superior to the zy-omatic arch. The superior temporal line wasost superior extent of any ZTN distal fibers,

nd the mean distance from it to the frontozy-omatic suture was 12 mm. The ZTN wasound to communicate with the posteriorlyocated auriculotemporal branch of the man-ibular nerve on 13% of sides and anteriorlyith the lacrimal nerve on 8.7% of sides.For variations, the ZTN has been reported

o rarely travel through the sphenomaxillaryssure into the temporal fossa, although thisxit site is usually directly through bone andot a suture (Figure 3) (2). The nerve may bebsent, and if small, its territory may be com-ensated for by additional branches of the lac-imal nerve (2). Two branches of the ZTN maye seen (8). We found 1 (4.2%) specimen (leftide) for which no ZTN was identified. Addi-ionally, in 2 (8.7%) specimens, communica-ion was identified between the ZTN and the

ore anteriorly located cutaneous branchesf the lacrimal nerve. No arterial branches

Figure 3. Dry skull illustrating the details ofthe internal aspect of the right orbit. Note theinferior orbital fissure (red line) and the exitsite (yellow line) for the zygomaticotemporalnerve from the orbit to the temporal fossa.

ere noted to travel with the ZTN; however,

, NOVEMBER 2012 ww

atellite arteries are found to accompany itseighboring nerve, the zygomatic facial nerve.

Theoretically and in addition, inadvertentraction on the ZTN during pterional craniot-mies may damage the postganglionic fibers

hat this nerve carries more deeply to the lac-imal gland, resulting in a desiccated cornea.lthough we were unable to find such a rela-

ionship reported in the literature, such aomplication may be underappreciated be-ause so little is published about the surgicalnatomy of the ZTN.

ONCLUSIONS

ased on our study, the ZTN has a fairly stan-ard course that takes it along a superficialathway overlying the pterion. It is our hope

hat with a greater appreciation for its anat-my and landmarks for its localization, injury

o the ZTN may be avoided during surgicalrocedures in its territory, and if entrapped,ay be more easily identified by the surgeon.

REFERENCES

1. Andersen NB, Bovim G, Sjaastad O: The frontotempo-ral peripheral nerves. Topographic variations of thesupraorbital, supratrochlear and auriculotemporalnerves and their possible clinical significance. SurgRadiol Anat 23:97-104, 2001.

2. Bergmann RA, Thompson S, Afifi A: Catalog of Hu-man Anatomic Variation. Baltimore: Vol Urban &Schwarzenberg, 1984.

3. Gee JR, Ishaq Y, Vijayan N: Postcraniotomy head-ache. Headache 43:276-278, 2003.

4. Govsa F, Celik S, Ozer MA: Orbital restoration sur-gery in the zygomaticotemporal and zygomaticofa-cial nerves and important anatomic landmarks. JCraniofac Surg 20:540-544, 2009.

5. Guyuron B, Kriegler JS, Davis J, Amini SB: Compre-hensive surgical treatment of migraine headaches.Plast Reconstr Surg 115:1-9, 2005.

6. Guyuron B, Tucker T, Davis J: Surgical treatment ofmigraine headaches. Plast Reconstr Surg 109:2183-2189, 2002.

7. Hwang K, Suh MS, Lee SI, Chung IH: Zygomatico-temporal nerve passage in the orbit and temporalarea. J Craniofac Surg 15:209-214, 2004.

8. Janis JE, Hatef DA, Thakar H, Reece EM, McCluskeyPD, Schaub TA, Theivagt C, Guyuron B: The zygo-maticotemporal branch of the trigeminal nerve: partII. Anatomical variations. Plast Reconstr Surg 126:435-442, 2010.

9. Jeong SM, Park KJ, Kang SH, Shin HW, Kim H, LeeHK, Chung YG: Anatomical consideration of the

anterior and lateral cutaneous nerves in the scalp. JKorean Med Sci 25:517-522, 2010.

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10. Loukas M, Owens DG, Tubbs RS, Spentzouris G,Elochukwu A, Jordan R: Zygomaticofacial, zygoma-ticoorbital and zygomaticotemporal foramina: ana-tomical study. Anat Sci Int 83:77-82, 2008.

1. Poggi JT, Grizzell BE, Helmer SD: Confirmation ofsurgical decompression to relieve migraine head-aches. Plast Reconstr Surg 122:115-122; discussion123-114, 2008.

2. Rocha-Filho PA, Gherpelli JL, de Siqueira JT, RabelloGD: Post-craniotomy headache: characteristics,

cc

Sasha Gulati1,2,3, Asgeir Store Jakola1,3,

nately, older patients are under-represented

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behaviour and effect on quality of life in patients oper-ated for treatment of supratentorial intracranial aneu-rysms. Cephalalgia 28:41-48, 2008.

3. Totonchi A, Pashmini N, Guyuron B: The zygomatico-temporal branch of the trigeminal nerve: an anatomi-cal study. Plast Recontr Surg 115:273-277, 2005.

onflict of interest statement: The authors declare thathe article content was composed in the absence of any

ommercial or financial relationships that could beonstrued as a potential conflict of interest.

Tom Børge Johannesen4, Ole Solheim1,

ion of the elderly limits generalization re-

spc

WORLD NEUROSURGE

eceived 13 April 2011; accepted 09 September 2011;ublished online 01 November 2011

itation: World Neurosurg. (2012) 78, 5:515-518.OI: 10.1016/j.wneu.2011.09.028

ournal homepage: www.WORLDNEUROSURGERY.org

vailable online: www.sciencedirect.com

878-8750/$ - see front matter © 2012 Elsevier Inc.ll rights reserved.

Survival and Treatment Patterns of Glioblastoma in the Elderly:A Population-Based Study

3

INTRODUCTION

The incidence of glioblastoma increaseswith advancing age, reaching its peak afterthe age of 65 years (49). As the older seg-ment of the population grows faster thanany other age group, the number of elderlydiagnosed with glioblastoma is expected toincrease. Neurosurgeons and neurooncolo-gists will therefore increasingly be asked toprovide treatment recommendations for el-derly patients with glioblastoma. Unfortu-

Key words� Age� Glioblastoma� Survival

Abbreviations and AcronymsCI: Confidence intervalHR: Hazard ratioICD: International Classification of Diseases

From the 1Department of Neurosurgery, St.Olavs Hospital, Trondheim; 2Department of

aboratory Medicine, Children’s and Women’s Health,orwegian University of Science and Technology,rondheim; 3MI Lab and Department of Neuroscience,orwegian University of Science and Technology,rondheim; and 4The Norwegian Cancer Registry,

Oslo, Norway

To whom correspondence should be addressed:Sasha Gulati, M.D. [E-mail: sashagulati@hotmail.com]

Citation: World Neurosurg. (2012) 78, 5:518-526.DOI: 10.1016/j.wneu.2011.12.008

Journal homepage: www.WORLDNEUROSURGERY.org

Available online: www.sciencedirect.com

1878-8750/$ - see front matter © 2012 Published byElsevier Inc.

n clinical treatment trials. The lack of clin-cal trials with proportionate representa-

� BACKGROUND: As the older segmeother age group, the number of elderly dincrease. The aim of this study was toto elderly patients diagnosed with gliobfurther studied whether increased treatma clinically important survival benefit in

� METHODS: From the Norwegian Cawho were diagnosed with glioblastom

� RESULTS: The proportion of patien15.9% of patients (n � 459) were >7aried significantly between age grouere less likely to receive multimoda

adiotherapy and/or chemotherapy. Elddiagnosis of glioblastoma without

mong patients receiving multimodalherapy, and chemotherapy, shorter suelonging to the age group >75 yearsurvival (P < 0.001), thus seemingly off care. Increasing age, no tumor resepy were identified as independent prtatistically significant, albeit debatabor the oldest patients (>75 years) dia

CONCLUSIONS: Advancing age reegative prognostic factor in glioblast

n the aggressiveness of treatment pain for the oldest age group seems aldest age group remains very poor, d

ults to older patients as age is a knownrognostic factor. Older patients may be ex-

f the population grows faster than anyosed with glioblastoma is expected tore survival and the treatment provided

oma in a population-based setting. Weggressiveness may have contributed toelderly population.

r Registry, we included 2882 patientstween 1988 and 2008.

66 years was 42.5% (n � 1224), andars at diagnosis. Treatment patterns

< 0.001). Elderly patients (66 years)atment with resection combined withpatients were more likely to receive

opathologic verification (P < 0.001).tment with surgical resection, radio-l was seen in the elderly (P < 0.001).the strongest predictor of decreased

er prognostic impact than the patterns, no radiotherapy, and no chemother-

tors of reduced survival. There was alinically relevant survival advantage

sed in the last 5 years of the study.

ns a very strong and independentAlthough there has been an increaseed to elderly with glioblastoma, thest very modest. The prognosis of thete multimodal treatment.

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RY, DOI:10.1016/j.wneu.2011.12.008