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Jang TG, Cha SH, Cho WH. Contralateral Interhemispheric Transcallosal Approach for Thalamic Cystic Cavernous Malformation. Brain Tumor Res Treat 2021; 9:87-92. [PMID: 34725990 PMCID: PMC8561222 DOI: 10.14791/btrt.2021.9.e15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/28/2021] [Indexed: 11/23/2022] Open
Abstract
A 42-year-old man presented with a headache and right hemiparesis and was found to have a cystic mass with a calcified mural nodule in the left thalamus. Because the thalamus is surrounded by vital neurovascular structures, the surgical approach to thalamic lesions can be challenging. We decided to remove the mass for decompression and pathological diagnosis. The mass was removed through a contralateral interhemispheric transcallosal transchoroidal approach with less retraction and parenchymal injury than other approaches to avoid brain retraction and cortical injury. The pathological diagnosis was cavernous malformation. Temporary worsening of the preoperative hemiparesis was recovered over two months following surgery. Tolerable thalamic pain syndrome remained. Here, we report a rare case of thalamic cavernous malformation with a favorable outcome through a contralateral surgical approach.
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Affiliation(s)
- Tak Gun Jang
- Department of Neurosurgery, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
| | - Seung Heon Cha
- Department of Neurosurgery, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea.
| | - Won Ho Cho
- Department of Neurosurgery, Pusan National University Hospital, Pusan National University College of Medicine, Busan, Korea
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López López LB, Moles Herbera JA, Vázquez Sufuentes S, Fustero de Miguel D, Avedillo Ruidíaz A, Orduna Martínez J, Pellejero JC. Supracerebellar transtentorial approach for left parahippocampal cavernous malformation. Surg Neurol Int 2021; 12:216. [PMID: 34084643 PMCID: PMC8168674 DOI: 10.25259/sni_166_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/05/2021] [Indexed: 11/08/2022] Open
Abstract
Background: Lesions in the temporomesial region can be reached by various approaches: subtemporal, transsylvian, transcortical, interhemispheric parieto-occipital, or supracerebellar transtentorial (SCTT). The choice varies according to the characteristics of the lesion and neighboring structures. Case Description: In this clinical case, it is presented a 56-year-old man with long-term evolution of drug-resistant epilepsy secondary to a cavernoma in the left parahippocampal gyrus. After assessing the lesion, it was decided a SCTT approach for its resection in a semi-sitting position, to avoid language disorders or visual damage. The surgery was uneventful and the patient did not present epileptic seizures during 6-month follow-up. Conclusion: Performing a SCTT is safe and feasible option for resection of lesions located in the basal temporomesial region without causing damage to neighboring structures, especially those located in the middle and posterior two-thirds of temporal region.
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Mascitelli J, Burkhardt JK, Gandhi S, Lawton MT. Contralateral Supracerebellar-Infratentorial Approach for Resection of Thalamic Cavernous Malformations. Oper Neurosurg (Hagerstown) 2018; 15:404-411. [DOI: 10.1093/ons/opy004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 12/12/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Surgical resection of cavernous malformations (CM) in the posterior thalamus, pineal region, and midbrain tectum is technically challenging owing to the presence of adjacent eloquent cortex and critical neurovascular structures. Various supracerebellar infratentorial (SCIT) approaches have been used in the surgical armamentarium targeting lesions in this region, including the median, paramedian, and extreme lateral variants. Surgical view of a posterior thalamic CM from the traditional ipsilateral vantage point may be obscured by occipital lobe and tentorium.
OBJECTIVE
To describe a novel surgical approach via a contralateral SCIT (cSCIT) trajectory for resecting posterior thalamic CMs.
METHODS
From 1997 to 2017, 75 patients underwent the SCIT approach for cerebrovascular/oncologic pathology by the senior author. Of these, 30 patients underwent the SCIT approach for CM resection, and 3 patients underwent the cSCIT approach. Historical patient data, radiographic features, surgical technique, and postoperative neurological outcomes were evaluated in each patient.
RESULTS
All 3 patients presented with symptomatic CMs within the right posterior thalamus with radiographic evidence of hemorrhage. All surgeries were performed in the sitting position. There were no intraoperative complications. Neuroimaging demonstrated complete CM resection in all cases. There were no new or worsening neurological deficits or evidence of rebleeding/recurrence noted postoperatively.
CONCLUSION
This study establishes the surgical feasibility of a contralateral SCIT approach in resection of symptomatic thalamic CMs It demonstrates the application for this procedure in extending the surgical trajectory superiorly and laterally and maximizing safe resectability of these deep CMs with gravity-assisted brain retraction.
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Affiliation(s)
- Justin Mascitelli
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Sirin Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
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Abstract
Cavernous malformations of the thalamus represent a particularly complex subset of cavernous malformations because of the highly eloquent nature of the involved tissue and their deep location. The decision about whether to operate on any individual lesion depends on the specific location of the lesion within the thalamus, the nature of the patient's symptoms, and the patient's history. When surgery is recommended, the approach must be chosen carefully. Each part of the thalamus is reached by a different surgical approach. These approaches include the orbitozygomatic approach to the anteroinferior thalamus, the anterior interhemispheric transcallosal approach to the medial thalamus, the anterior contralateral interhemispheric transcallosal approach to the lateral thalamus, the posterior interhemispheric transcallosal approach to the posterosuperior thalamus, the parieto-occipital transventricular approach to the lateral posteroinferior thalamus, and the suboccipital supracerebellar infratentorial/transtentorial approach to the medial posteroinferior thalamus. Careful attention to safe entry zones and image guidance can allow safe removal of these lesions when necessary.
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Affiliation(s)
- Christina E Sarris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Gursant S Atwal
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
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Tian KB, Zheng JJ, Ma JP, Hao SY, Wang L, Zhang LW, Wu Z, Zhang JT, Li D. Clinical course of untreated thalamic cavernous malformations: hemorrhage risk and neurological outcomes. J Neurosurg 2016; 127:480-491. [PMID: 27834594 DOI: 10.3171/2016.8.jns16934] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The natural history of cerebral cavernous malformations (CMs) has been widely studied, but the clinical course of untreated thalamic CMs is largely unknown. Hemorrhage of these lesions can be devastating. The authors undertook this study to obtain a prospective hemorrhage rate and provide a better understanding of the prognosis of untreated thalamic CMs. METHODS This longitudinal cohort study included patients with thalamic CMs who were diagnosed between 2000 and 2015. Clinical data were recorded, radiological studies were extensively reviewed, and follow-up evaluations were performed. RESULTS A total of 121 patients were included in the study (56.2% female), with a mean follow-up duration of 3.6 years. The overall annual hemorrhage rate (subsequent to the initial presentation) was calculated to be 9.7% based on the occurrence of 42 hemorrhages over 433.1 patient-years. This rate was highest in patients (n = 87) who initially presented with hemorrhage and focal neurological deficits (FNDs) (14.1%) (χ2 = 15.358, p < 0.001), followed by patients (n = 19) with hemorrhage but without FND (4.5%) and patients (n = 15) without hemorrhage regardless of symptoms (1.2%). The initial patient presentations of hemorrhage with FND (hazard ratio [HR] 2.767, 95% CI 1.336-5.731, p = 0.006) and associated developmental venous anomaly (DVA) (HR 2.510, 95% CI 1.275-4.942, p = 0.008) were identified as independent hemorrhage risk factors. The annual hemorrhage rate was significantly higher in patients with hemorrhagic pres entation at diagnosis (11.7%, p = 0.004) or DVA (15.7%, p = 0.002). Compared with the modified Rankin Scale (mRS) score at diagnosis (mean 2.2), the final mRS score (mean 2.0) was improved in 37 patients (30.6%), stable in 59 patients (48.8%), and worse in 25 patients (20.7%). Lesion size (odds ratio [OR] per 0.1 cm increase 3.410, 95% CI 1.272-9.146, p = 0.015) and mRS score at diagnosis (OR per 1 point increase 3.548, 95% CI 1.815-6.937, p < 0.001) were independent adverse risk factors for poor neurological outcome (mRS score ≥ 2). Patients experiencing hemorrhage after the initial ictus (OR per 1 ictus increase 6.923, 95% CI 3.023-15.855, p < 0.001) had a greater chance of worsened neurological status. CONCLUSIONS This study verified the adverse predictors for hemorrhage and functional outcomes of thalamic CMs and demonstrated an overall annual symptomatic hemorrhage rate of 9.7% after the initial presentation. These findings and the mode of initial presentation are useful for clinicians and patients when selecting an appropriate treatment, although the tertiary referral bias of the series should be taken into account.
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Affiliation(s)
- Kai-Bing Tian
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Jing-Jie Zheng
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Jun-Peng Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Shu-Yu Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Liang Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Li-Wei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Jun-Ting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
| | - Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University.,Beijing Key Laboratory of Brian Tumor, Beijing; and
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Grigoryan YA, Sitnikov AR, Timoshenkov AV, Grigoryan GY. [The paramedian supracerebellar transtentorial approach to the mediobasal temporal region]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2016; 80:48-62. [PMID: 27500774 DOI: 10.17116/neiro201680448-62] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
UNLABELLED The mediobasal temporal region (MTR) is located near the brain stem and surrounded by the eloquent neurovascular structures. The supracerebellar transtentorial approach (STA) is safe access to the posterior MTR structures, however its use for resection of anterior MTR lesions still remains controversial. The article describes the technique and outcome of surgery for different MTR structures using STA. MATERIAL AND METHODS The paramedian STA was used in 18 patients (13 females and 5 males) for 7 years. Ten patients presented with glial MTR tumors, 3 patients with cavernomas, 2 patients with arteriovenous malformations (AVMs), 2 patients with intraventricular meningiomas, and 1 patient with mesial temporal sclerosis. The patient age ranged from 19 to 57 years. In 10 cases, lesions were localized on the left. Epilepsy was the leading symptom in 14 cases. Patients underwent preoperative high-resolution MRI, electroencephalography video monitoring before and after surgery, intraoperative corticography (if necessary), and postoperative CT and MRI. RESULTS Lesions were located in the anterior third of MTR in 5 patients, in the anterior and middle thirds in 2 patients, in the middle third in 5 patients, in the middle and posterior thirds in 2 patients, in the posterior third in 1 patient, in the anterior, middle, and posterior thirds in 1 patient, and in the ventricular triangle area in 2 patients. In all patients with intraventricular tumors, AVMs, and cavernous malformations and in 8 patients with glial MTR tumors, the lesions were totally resected. Two patients with intracerebral tumors underwent subtotal resection. A patient with intractable epilepsy and mesial temporal sclerosis underwent resection of the anterior two-thirds of the hippocampus and parahippocampal gyrus and, partially, amygdala using intraoperative corticography. There was no surgical mortality; 2 patients developed a transient neurological deficit, and 1 patient had a cerebellar hematoma that was successfully removed during surgery. CONCLUSION STA enables resection of lesions localized in all parts of the MTR, without damage to the surrounding nerve and vascular structures.
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Affiliation(s)
- Yu A Grigoryan
- Federal Center of Treatment and Rehabilitation, Moscow, Russia
| | - A R Sitnikov
- Federal Center of Treatment and Rehabilitation, Moscow, Russia
| | - A V Timoshenkov
- Federal Center of Treatment and Rehabilitation, Moscow, Russia
| | - G Yu Grigoryan
- Federal Center of Treatment and Rehabilitation, Moscow, Russia
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Scranton RA, Fung SH, Britz GW. Transulcal parafascicular minimally invasive approach to deep and subcortical cavernomas: technical note. J Neurosurg 2016; 125:1360-1366. [PMID: 26943846 DOI: 10.3171/2015.12.jns152185] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cavernomas comprise 8%-15% of intracranial vascular lesions, usually supratentorial in location and superficial. Cavernomas in the thalamus or subcortical white matter represent a unique challenge for surgeons in trying to identify and then use a safe corridor to access and resect the pathology. Previous authors have described specific open microsurgical corridors based on pathology location, often with technical difficulty and morbidity. This series presents 2 cavernomas that were resected using a minimally invasive approach that is less technically demanding and has a good safety profile. The authors report 2 cases of cavernoma: one in the thalamus and brainstem with multiple hemorrhages and the other in eloquent subcortical white matter. These lesions were resected through a transulcal parafascicular approach with a port-based minimally invasive technique. In this series there was complete resection with no neurological complications. The transulcal parafascicular minimally invasive approach relies on image interpretation and trajectory planning, intraoperative navigation, cortical cannulation and subcortical space access, high-quality optics, and resection as key elements to minimize exposure and retraction and maximize tissue preservation. The authors applied this technique to 2 patients with cavernomas in eloquent locations with excellent outcomes.
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Affiliation(s)
| | - Steve H Fung
- Radiology, Houston Methodist Neurological Institute, Houston, Texas
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Villanueva P, Louis RG, Cutler AR, Wei H, Sale D, Duong HT, Barkhoudarian G, Kelly DF. Endoscopic and Gravity-Assisted Resection of Medial Temporo-occipital Lesions Through a Supracerebellar Transtentorial Approach: Technical Notes With Case Illustrations. Oper Neurosurg (Hagerstown) 2015; 11:475-483. [PMID: 29506159 DOI: 10.1227/neu.0000000000000970] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 06/22/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Traditional approaches to medial temporo-occipital intra-axial brain tumors carry the risk of visual or language deficits related to brain retraction or transgression of deep fiber tracts. To reduce these risks, the microscopic supracerebellar transtentorial approach with the patient in the sitting position has been previously described for lesions in relative proximity to the tentorium. OBJECTIVE We describe this approach performed with endoscopic tumor resection to allow better visualization and a more ergonomic operating position. METHODS Four consecutive patients harboring a medial temporo-occipital lesion are reported. All were operated on while in the sitting position using frameless navigation and a supracerebellar transtentorial approach. Tumor resection was performed by 2 surgeons with endoscopic visualization. RESULTS Pathologies included intraparenchymal metastatic melanoma, cavernous hemangioma, and ganglioglioma, as well as an intraventricular metastatic tumor. The distance from the tentorium to the lesion ranged from 1 to 4 mm. Gross total resection was achieved in 3 of the 4 patients. The patient with a metastatic melanoma had an intentional near-total resection given the tumor encasing a branch of the posterior cerebral artery. The patient with the intraventricular tumor sustained a small but symptomatic infarct of the lateral geniculate region, resulting in a visual field deficit. CONCLUSION This small series suggests that the endoscopic supracerebellar transtentorial approach with the patient in the sitting position can be a safe and effective approach for removing medial temporo-occipital lesions. It allows excellent tumor visualization, eliminates the need for brain retraction, minimizes parenchymal transgression, and improves surgical ergonomics. Significant experience in endoscopy and excellent neuroanesthesia support are recommended before undertaking this approach.
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Affiliation(s)
- Pablo Villanueva
- Department of Neurosurgery, Catholic University of Chile, Santiago, Chile
| | - Robert G Louis
- ONE Brain and Spine Center, Hoag Memorial Hospital Presbyterian, Newport Beach, California
| | | | - Hua Wei
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Danjuma Sale
- Department of Surgery, Neurosurgery Unit, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria
| | - Huy T Duong
- Department of Neurosurgery, Kaiser Medical Center Sacramento, Sacramento, California
| | - Garni Barkhoudarian
- Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California
| | - Daniel F Kelly
- Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California
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Aboul-Enein H, El-Aziz Sabry AA, Hafez Farhoud A. Supracerebellar infratentorial approach with paramedian expansion for posterior third ventricular and pineal region lesions. Clin Neurol Neurosurg 2015; 139:100-9. [DOI: 10.1016/j.clineuro.2015.08.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 08/10/2015] [Accepted: 08/11/2015] [Indexed: 11/29/2022]
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Rangel-Castilla L, Spetzler RF. The 6 thalamic regions: surgical approaches to thalamic cavernous malformations, operative results, and clinical outcomes. J Neurosurg 2015; 123:676-85. [PMID: 26024002 DOI: 10.3171/2014.11.jns14381] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The ideal surgical approach to thalamic cavernous malformations (CMs) varies according to their location within the thalamus. To standardize surgical approaches, the authors have divided the thalamus into 6 different regions and matched them with the corresponding surgical approach. METHODS The regions were defined as Region 1 (anteroinferior), Region 2 (medial), Region 3 (lateral), Region 4 (posterosuperior), Region 5 (lateral posteroinferior), and Region 6 (medial posteroinferior). The senior author's surgical experience with 46 thalamic CMs was reviewed according to this classification. An orbitozygomatic approach was used for Region 1; anterior ipsilateral transcallosal for Region 2; anterior contralateral transcallosal for Region 3; posterior transcallosal for Region 4; parietooccipital transventricularfor Region 5; and supracerebellar-infratentorial for Region 6. RESULTS Region 3 was the most common location (17 [37%]). There were 5 CMs in Region 1 (11%), 9 in Region 2 (20%), 17 in Region 3 (37%), 3 in Region 4 (6%), 4 in Region 5 (9%), and 8 in Region 6 (17%). Complete resection was achieved in all patients except for 2, who required a second-stage operation. The mean follow-up period was 1.7 years (range 6 months-9 years). At the last clinical follow-up, 40 patients (87%) had an excellent or good outcome (modified Rankin Scale [mRS] scores 0-2) and 6 (13%) had poor outcome (mRS scores 3-4). Relative to their preoperative condition, 42 patients (91%) were unchanged or improved, and 4 (9%) were worse. CONCLUSIONS The authors have presented the largest series reported to date of surgically treated thalamic CMs, achieving excellent results using this methodology. In the authors' experience, conceptually dividing the thalamus into 6 different regions aids in the selection of the ideal surgical approach fora specific region.
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Affiliation(s)
- Leonardo Rangel-Castilla
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert F Spetzler
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Weil AG, Middleton AL, Niazi TN, Ragheb J, Bhatia S. The supracerebellar-transtentorial approach to posteromedial temporal lesions in children with refractory epilepsy. J Neurosurg Pediatr 2015; 15:45-54. [PMID: 25396700 DOI: 10.3171/2014.10.peds14162] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Operations on tumors of the posteromedial temporal (PMT) region, that is, on those arising from the posterior parahippocampal, fusiform, and lingual gyri, are challenging to perform because of the deep-seated location of these tumors between critical cisternal neurovascular structures and the adjacent temporal and occipital cortexes. Traditional surgical approaches require temporal or occipital transgression, retraction, or venous sacrifice. These approaches may result in unintended complications that should be avoided. To avoid these complications, the supracerebellar-transtentorial (SCTT) approach to this region has been used as an effective alternative treatment in adult patients. The SCTT approach uses a sitting position that offers a direct route to the posterior fusiform and lingual gyri of the temporal lobe. The authors report the feasibility, safety, and efficacy of this approach, using a modified lateral park-bench position in a small cohort of pediatric patients. METHODS The authors carried out a retrospective case review of 5 consecutive patients undergoing a paramedian SCTT approach between 2009 and 2014 at the authors' institution. RESULTS The SCTT approach in the park-bench position was used in 3 boys and 2 girls with a mean age of 7.8 years (range 13 months to 16 years). All patients presented with a seizure disorder related to a tumor in a PMT region involving the parahippocampal and fusiform gyri of the left (n = 3) or right (n = 2) temporal lobe. No procedure-related complications were observed. Gross-total resection and control of seizures were achieved in all cases. Tumor classes and types included 1 Grade II astrocytoma, 1 pleomorphic xanthoastrocytoma, 1 ganglioglioma, and 2 glioneural tumors. None of the tumors had recurred by the mean follow-up of 22 months (range 1-48 months). Outcomes of epileptic seizures were excellent, with seizure symptoms in all 5 patients scoring in Engel Class IA. CONCLUSIONS The SCTT approach represents a viable option when resecting tumors in this region, providing a reasonable working corridor and low morbidity. The authors' experience in a cohort of pediatric patients demonstrates that complete resection of the lesions in this location is feasible and is safe when involving an approach that involves using a park-bench lateral positioning.
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Affiliation(s)
- Alexander G Weil
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami Children's Hospital, Miami, Florida
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Cavernous Malformations of the Thalamus: A Relatively Rare but Controversial Entity. World Neurosurg 2013; 79:641-4. [DOI: 10.1016/j.wneu.2012.04.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 04/24/2012] [Indexed: 11/22/2022]
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Li D, Zhang J, Hao S, Tang J, Xiao X, Wu Z, Zhang L. Surgical Treatment and Long-Term Outcomes of Thalamic Cavernous Malformations. World Neurosurg 2013; 79:704-13. [DOI: 10.1016/j.wneu.2012.01.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2011] [Revised: 11/22/2011] [Accepted: 01/20/2012] [Indexed: 10/14/2022]
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de Oliveira JG, Párraga RG, Chaddad-Neto F, Ribas GC, de Oliveira EPL. Supracerebellar transtentorial approach—resection of the tentorium instead of an opening—to provide broad exposure of the mediobasal temporal lobe: anatomical aspects and surgical applications. J Neurosurg 2012; 116:764-72. [DOI: 10.3171/2011.12.jns111256] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The aim of this study was to describe the surgical anatomy of the mediobasal aspect of the temporal lobe and the supracerebellar transtentorial (SCTT) approach performed not with an opening, but with the resection of the tentorium, as an alternative route for the neurosurgical management of vascular and tumoral lesions arising from this region.
Methods
Cadaveric specimens were used to illustrate the surgical anatomy of the mediobasal region of the temporal lobe. Demographic aspects, characteristics of lesions, clinical presentation, surgical results, follow-up findings, and outcomes were retrospectively reviewed for patients referred to receive the SCTT approach with tentorial resection.
Results
Ten patients (83%) were female and 2 (17%) were male. Their ages ranged from 6 to 59 years (mean 34.5 ± 15.8 years). All lesions (3 posterior cerebral artery aneurysms, 3 arteriovenous malformations, 3 cavernous malformations, and 3 tumors) were completely excluded or resected. After a mean follow-up period of 143 months (range 10–240 months), the mean postoperative Glasgow Outcome Scale score was 4.9.
Conclusions
Knowledge of the surgical anatomy provides improvement for microsurgical approaches. The evolution from a small opening to a resection of the tentorium absolutely changed the exposure of the mediobasal aspect of the temporal lobe. The SCTT approach with tentorial resection is an excellent alternative route to the posterior part of mediobasal aspect of the temporal lobe, and it was enough to achieve the best neurosurgical management of tumoral and vascular lesions located in this area.
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Affiliation(s)
- Jean G. de Oliveira
- 1Microneurosurgery Laboratory, Institute of Neurological Sciences, Hospital Beneficência Portuguesa de São Paulo
- 2Division of Neurosurgery, School of Medicine, University Nove de Julho, São Paulo
| | - Richard Gonzalo Párraga
- 1Microneurosurgery Laboratory, Institute of Neurological Sciences, Hospital Beneficência Portuguesa de São Paulo
| | - Feres Chaddad-Neto
- 1Microneurosurgery Laboratory, Institute of Neurological Sciences, Hospital Beneficência Portuguesa de São Paulo
- 3Division of Neurosurgery, School of Medicine, State University of Campinas, Brazil
| | - Guilherme Carvalhal Ribas
- 1Microneurosurgery Laboratory, Institute of Neurological Sciences, Hospital Beneficência Portuguesa de São Paulo
- 4Clinical Anatomy Discipline, Department of Surgery–Laboratório de Investigação Médica–02, University of São Paulo Medical School
- 5Hospital Israelita Albert Einstein, São Paulo; and
| | - Evandro P. L. de Oliveira
- 1Microneurosurgery Laboratory, Institute of Neurological Sciences, Hospital Beneficência Portuguesa de São Paulo
- 3Division of Neurosurgery, School of Medicine, State University of Campinas, Brazil
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Chang EF, Gabriel RA, Potts MB, Berger MS, Lawton MT. Supratentorial cavernous malformations in eloquent and deep locations: surgical approaches and outcomes. Clinical article. J Neurosurg 2010; 114:814-27. [PMID: 20597603 DOI: 10.3171/2010.5.jns091159] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Resection of cavernous malformations (CMs) located in functionally eloquent areas of the supratentorial compartment is controversial. Hemorrhage from untreated lesions can result in devastating neurological injury, but surgery has potentially serious risks. We hypothesized that an organized system of approaches can guide operative planning and lead to acceptable neurological outcomes in surgical patients. METHODS The authors reviewed the presentation, surgery, and outcomes of 79 consecutive patients who underwent microresection of supratentorial CMs in eloquent and deep brain regions (basal ganglia [in 27 patients], sensorimotor cortex [in 23], language cortex [in 3], thalamus [in 6], visual cortex [in 10], and corpus callosum [in 10]). A total of 13 different microsurgical approaches were organized into 4 groups: superficial, lateral transsylvian, medial interhemispheric, and posterior approaches. RESULTS The majority of patients (93.7%) were symptomatic. Hemorrhage with resulting focal neurological deficit was the most common presentation in 53 patients (67%). Complete resection, as determined by postoperative MR imaging, was achieved in 76 patients (96.2%). Overall, the functional neurological status of patients improved after microsurgical dissection at the time of discharge from the hospital and at follow-up. At 6 months, 64 patients (81.0%) were improved relative to their preoperative condition and 14 patients (17.7%) were unchanged. Good outcomes (modified Rankin Scale score ≤ 2, living independently) were achieved in 77 patients (97.4%). Multivariate analysis of demographic and surgical factors revealed that preoperative functional status was the only predictor of postoperative modified Rankin Scale score (OR 4.6, p = 0.001). Six patients (7.6%) had transient worsening of neurological examination after surgery, and 1 patient (1.3%) was permanently worse. There was no surgical mortality. CONCLUSIONS The authors present a system of 13 microsurgical approaches to 6 location targets with 4 general trajectories to facilitate safe access to supratentorial CMs in eloquent brain regions. Favorable neurological outcomes following microsurgical resection justify an aggressive surgical attitude toward these lesions.
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Affiliation(s)
- Edward F Chang
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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Gross BA, Batjer HH, Awad IA, Bendok BR. CAVERNOUS MALFORMATIONS OF THE BASAL GANGLIA AND THALAMUS. Neurosurgery 2009; 65:7-18; discussion 18-9. [DOI: 10.1227/01.neu.0000347009.32480.d8] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
CAVERNOUS MALFORMATIONS OF the basal ganglia and thalamus present a unique therapeutic challenge to the neurosurgeon given their unclear natural history, the risk of surgical treatment, and the unproven efficacy of radiosurgical therapy. Via a PubMed search of the English and French literature, we have systematically reviewed the natural history and surgical and radiosurgical management of these lesions reported through April 2008. Including rates cited for “deep” cavernous malformations, annual bleeding rates for these lesions varied from 2.8% to 4.1% in the natural history studies. Across surgical series providing postoperative or long-term outcome data on 103 patients, we found an 89% resection rate, a 10% risk of long-term surgical morbidity, and a 1.9% risk of surgical mortality. The decrease in hemorrhage risk reported 2 years after radiosurgery might be a result of natural hemorrhage clustering, underscoring the unproven efficacy of this therapeutic modality. Given the compounded risks of radiation-induced injury and post-radiosurgical rebleeding, radiosurgery at modest dosimetry (12–14 Gy marginal doses) is only an option for patients with surgically inaccessible, aggressive lesions.
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Affiliation(s)
- Bradley A. Gross
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
| | - H. Hunt Batjer
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
| | - Issam A. Awad
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
| | - Bernard R. Bendok
- Department of Neurological Surgery, Feinberg School of Medicine and McGaw Medical Center, Northwestern University, Chicago, Illinois, and Division of Neurosurgery, Evanston Northwestern Healthcare, Evanston, Illinois
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