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Morota N, Deletis V. Brainstem Surgery: Functional Surgical Anatomy with the Use of an Advanced Modern Intraoperative Neurophysiological Procedure. Adv Tech Stand Neurosurg 2023; 48:21-55. [PMID: 37770680 DOI: 10.1007/978-3-031-36785-4_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Intraoperative neurophysiology (ION) in brainstem surgery evolved as brainstem surgery advanced.The original idea of brainstem mapping (BSM) is a neurophysiological procedure to locate cranial nerve motor nuclei (CNMN) on the floor of the fourth ventricle. With the introduction of various skull base approaches to the brainstem, BSM is carried out on any surface of the brainstem to expose the safe entry zone to the intrinsic brainstem lesion. It is the modern concept of BSM, a broader definition of BSM. BSM enables to avoid direct damage to the CNMN when approaching the brainstem through the negative mapping region.The corticobulbar tract (CBT) motor evoked potential (MEP) is another ION procedure in brainstem surgery. It enables monitoring of the functional integrity of the whole cranial motor pathway without interrupting surgical procedures. Combined application of both BSM and CBT-MEP monitoring is indispensable for the functional preservation of the CNMN and their supranuclear innervation during the brainstem surgery.In this paper, the neurophysiological aspect of BSM and the CBT-MEP was fully described. Normal anatomical background of the floor of the fourth ventricle and the detail of the CBT anatomy were demonstrated to better understand their clinical usefulness, limitations, and surgical implications derived from ION procedures. Finally, a future perspective in the role of ION procedures in brainstem surgery was presented. The latest magnetic resonance imaging (MRI) technology can allow surgeons to find an "on the image" safe entry zone to the brainstem. However, the role of BSM and the CBT-MEP monitoring in terms of safe brainstem surgery stays unshakable. Special attention was paid for the recent trend of management in diffuse intrinsic pontine gliomas. A new role of BSM during a stereotactic biopsy was discussed.It is the authors' expectation that the paper enhances the clinical application of a contemporary standard of the ION in brainstem surgery and supports safer brainstem surgery more than ever and in the future.
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Affiliation(s)
- Nobuhito Morota
- Department of Neurosurgery, Kitasato University Hospital, Sagamihara, Japan
| | - Vedran Deletis
- Department of Neurosurgery, University Hospital, Zagreb, Croatia
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Catapano JS, Rutledge C, Rumalla K, Raygor KP, Srinivasan VM, Koester SW, Kimata AR, Ma KL, Labib MA, Spetzler RF, Lawton MT. External validation of the Lawton brainstem cavernous malformation grading system in a cohort of 277 microsurgical patients. J Neurosurg 2022; 136:1231-1239. [PMID: 34598133 DOI: 10.3171/2021.3.jns204291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The brainstem cavernous malformation (BSCM) grading system predicts neurological outcomes associated with microsurgical resection and assists neurosurgeons in selecting patients for treatment. The predictive accuracy of the BSCM grading system should be validated in a large cohort from high-volume centers to generalize its use. METHODS An external validation cohort comprised patients with a BSCM resected by the senior author (M.T.L.) since the publication of the BSCM grading system and those resected by another neurosurgeon (R.F.S.) over a 16-year period. Size, crossing the axial midpoint, the presence of a developmental venous anomaly, patient age, and timing of last hemorrhage were used to assign BSCM grades from 0 to VII. Poor neurological outcomes were recorded as modified Rankin Scale scores > 2 at last follow-up examination. RESULTS A total of 277 patients were included in the study. The average BSCM grade was 3.9, and the majority of BSCMs (181 patients, 65%) were intermediate grade (grades III-V). Outcomes were predicted by BSCM grade, with good outcomes observed in 47 of 54 patients (87%) with low-grade BSCMs, in 135 of 181 patients (75%) with intermediate-grade BSCMs, and in 21 of 42 patients (50%) with high-grade BSCMs. Conversely, proportions of patients with neurological deterioration increased with increasing BSCM grade, with worsening observed in 2 of 54 patients (4%) with low-grade BSCMs, in 29 of 181 patients (16%) with intermediate-grade BSCMs, and in 17 of 42 patients (40%) with high-grade BSCMs. In the chi-square analysis, high-grade BSCMs were associated with increased odds of neurological worsening compared to low- and intermediate-grade BSCMs (OR 5.0, 95% CI 2.4-10.4; p < 0.001). The receiver operating characteristic analysis demonstrated acceptable discrimination for predicting unfavorable functional outcomes (modified Rankin Scale score > 2) with an area under the curve of 0.74 (95% CI 0.68-0.80; p < 0.001). CONCLUSIONS This study validates the BSCM grading system in a large cohort of patients from two high-volume surgeons. BSCM grade predicted neurological outcomes with accuracy comparable to that of other grading systems in widespread use. The BSCM grading system establishes categories of low-, intermediate-, and high-grade BSCMs and a boundary or cutoff for surgery at BSCM grade V. BSCM grading guides the analysis of a particular patient's condition, but treatment recommendations must be individualized, and neurosurgeons must calibrate BSCM grading to their own outcome results, unique abilities, and practices.
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Affiliation(s)
- Joshua S Catapano
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Caleb Rutledge
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Kavelin Rumalla
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Kunal P Raygor
- 2Department of Neurosurgery, University of California, San Francisco, California
| | - Visish M Srinivasan
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Stefan W Koester
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Anna R Kimata
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Kevin L Ma
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Mohamed A Labib
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Robert F Spetzler
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Michael T Lawton
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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Dziedzic TA, Abhinav K, Fernandez-Miranda JC. Subtemporal Approach and Its Infratentorial Extension: Review and a Comparative Analysis of Different Techniques. J Neurol Surg B Skull Base 2022; 84:89-97. [PMID: 36743711 PMCID: PMC9897897 DOI: 10.1055/s-0041-1741566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/03/2021] [Indexed: 02/07/2023] Open
Abstract
Introduction Surgical resection of lesions occupying the incisural space is challenging. In a comparative fashion, we aimed to describe the anatomy and surgical approaches to the tentorial incisura and to the rostral brainstem via the intradural subtemporal approach and its infratentorial extensions. Methods Six fresh human head specimens (12 sides) were prepared for the microscopic dissection of the tentorial incisura using the intradural subtemporal approach and its infratentorial extensions. Endoscope was used to examine the anatomy of the region inadequately exposed with the microscope. Image-guided navigation was used to confirm bony structures visualized around the petrous apex. Results Standard subtemporal approach provides surgical access to the supratentorial brainstem above the pontomesencephalic sulcus and to the lateral surface of the cerebral peduncle. The linear or triangular tentorial divisions can provide access to the infratentorial space below the pontomesencephalic sulcus. The triangular tentorial flap in comparison with the linear incision obstructs the exposure of anterior incisural space and of the prepontine cistern. Visualization of the brainstem below the trigeminal nerve can be achieved by the anterior petrosectomy. Conclusion Infratentorial extension of the intradural subtemporal approach is technically demanding due to critical neurovascular structures and a relatively narrow corridor. In-depth anatomical knowledge is essential for the selection of the appropriate operative approach and safe surgical resections of lesions.
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Affiliation(s)
| | - Kumar Abhinav
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Center for Skull Base and Pituitary Neurosurgery, Southmead Hospital, Bristol, United Kingdom
| | - Juan C. Fernandez-Miranda
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States,Address for correspondence Juan C. Fernandez-Miranda, MD Department of Neurosurgery, Stanford University School of Medicine300 Pasteur Drive, Stanford, California, CA 94305-5327United States
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Huang C, Bertalanffy H, Kar S, Tsuji Y. Microsurgical management of midbrain cavernous malformations: does lesion depth influence the outcome? Acta Neurochir (Wien) 2021; 163:2739-2754. [PMID: 34415444 PMCID: PMC8437888 DOI: 10.1007/s00701-021-04915-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/16/2021] [Indexed: 11/28/2022]
Abstract
Background The purpose of this study was to clarify whether the intrinsic depth of midbrain cavernous malformations (MCMs) influenced the surgical outcome. Methods The authors conducted a retrospective study of 76 consecutive patients who underwent microsurgical resection of a MCM. The vascular lesions were categorized into 4 distinct groups based on how these lesions had altered the brainstem surface. Additionally, it was verified whether the actual aspect of the brainstem surface could be predicted only by evaluating the pertinent preoperative MRI slices. Clinical outcome was assessed by determining the modified Rankin Scale Score (mRS) before and after surgery. Results Twenty-three MCMs (30.3%) were located deeply within the midbrain. The overlying midbrain surface appeared to be normal (group nl). In 33 patients (43.4%), the midbrain surface showed only a yellowish discoloration (group yw). In another 14 individuals (18.4%), the midbrain surface was distorted by the underlying MCM and bulging out while the vascular lesion still remained covered by a thin parenchymal layer (group bg). In the smallest group comprising 6 patients (7.9%), the exophytic MCM had disrupted the midbrain surface and was clearly visible at microsurgical exposure (group ex). The mean mRS decreased in the group nl from 1.43 preoperatively to 0.61 at follow-up. Conclusion This study demonstrates in a large patient population that a deep intrinsic MCM location is not necessarily associated with an unfavorable clinical outcome after microsurgical lesionectomy. Predicting the aspect of the midbrain surface by evaluating preoperative MR images alone was not sufficiently reliable.
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Affiliation(s)
- Caiquan Huang
- Department of Neurosurgery, International Neuroscience Institute (INI), Rudolf Pichlmayr-Strasse 4, 30625, Hannover, Germany
- Department of Neurosurgery, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Helmut Bertalanffy
- Department of Neurosurgery, International Neuroscience Institute (INI), Rudolf Pichlmayr-Strasse 4, 30625, Hannover, Germany.
| | - Souvik Kar
- Department of Neurosurgery, International Neuroscience Institute (INI), Rudolf Pichlmayr-Strasse 4, 30625, Hannover, Germany
| | - Yoshihito Tsuji
- Department of Neurosurgery, International Neuroscience Institute (INI), Rudolf Pichlmayr-Strasse 4, 30625, Hannover, Germany
- Department of Neurosurgery, Matsubara Tokushukai Hospital, Matsubara, Japan
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Giammattei L, Starnoni D, Benes V, Froelich S, Cossu G, Borsotti F, Májovsky M, Sufianov AA, Fava A, di Russo P, Elbabaa SK, González-López P, Messerer M, Daniel RT. Extreme Lateral Supracerebellar Infratentorial Approach: Surgical Anatomy and Review of the Literature. World Neurosurg 2021; 147:89-104. [PMID: 33333288 DOI: 10.1016/j.wneu.2020.12.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/05/2020] [Accepted: 12/07/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The extreme lateral supracerebellar infratentorial (ELSI) approach has the potential to access several distinct anatomical regions that are otherwise difficult to reach. We have illustrated the surgical anatomy through cadaveric dissections and provided an extensive review of the literature to highlight the versatility of this approach, its limits, and comparisons with alternative approaches. METHODS The surgical anatomy of the ELSI has been described using 1 adult-injected cadaveric head. Formalized noninjected brain specimens were also dissected to describe the brain parenchymal anatomy of the region. An extensive review of the literature was performed according to each targeted anatomical region. Illustrative cases are also presented. RESULTS The ELSI approach allows for wide exposure of the middle and posterolateral incisural spaces with direct access to centrally located intra-axial structures such as the splenium, pulvinar, brainstem, and mesial temporal lobe. In addition, for skull base extra-axial tumors such as petroclival meningiomas, the ELSI approach represents a rapid and adequate method of access without the use of extensive skull base approaches. CONCLUSIONS The ELSI approach represents one of the most versatile approaches with respect to its ability to address several anatomical regions centered at the posterior and middle incisural spaces. For intra-axial pathologies, the approach allows for access to the central core of the brain with several advantages compared with alternate approaches that frequently involve significant brain retraction and cortical incisions. In specific cases of skull base lesions, the ELSI approach is an elegant alternative to traditionally used skull base approaches, thereby avoiding approach-related morbidity.
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Affiliation(s)
| | - Daniele Starnoni
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Vladimir Benes
- Department of Neurosurgery, Charles University and Military University Hospital, Prague, Czech Republic
| | | | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Francois Borsotti
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Martin Májovsky
- Department of Neurosurgery, Charles University and Military University Hospital, Prague, Czech Republic
| | - Albert A Sufianov
- Department of Neurosurgery, Federal Centre of Neurosurgery, Tyumen, Russia; Department of Neurosurgery, Sechenov University, Moscow, Russia
| | - Arianna Fava
- Department of Neurosurgery, Lariboisière Hospital, Paris, France
| | - Paolo di Russo
- Department of Neurosurgery, Lariboisière Hospital, Paris, France
| | - Samer K Elbabaa
- Department of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Pablo González-López
- Department of Neurosurgery, Hospital General Universitario de Alicante, Alicante, Spain
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland; Department of Neurosurgery, Sechenov University, Moscow, Russia; Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
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Spennato P, Chiaramonte C, Russo C, Onorini N, Mirone G, Mazio F, Di Martino G, Parlato RS, Cinalli G. Subtemporal Transtentorial Approach in Mesencephalic and Perimesencephalic Lesions in Children-A Series of 20 Patients. Oper Neurosurg (Hagerstown) 2020; 18:349-362. [PMID: 31504862 DOI: 10.1093/ons/opz254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 06/08/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Midbrain and surrounding areas are among the most difficult regions to surgically approach in neurosurgery. The subtemporal approach is a well-known neurosurgical approach that is rarely described in children. OBJECTIVE To assess the feasibility, advantages, and disadvantages of subtemporal approach in children. METHODS A total of 20 pediatric patients with intra-axial tumors involving the lateral midbrain or superior cerebellar peduncle or with extra-axial tumors in the middle incisural space/Meckel cave underwent subtemporal transtentorial approaches with the aim to remove (16 cases) or biopsy (4 cases) their lesions. These cases were retrospectively reviewed and the surgical approach described. RESULTS Total resection was achieved in 11 patients. In the 4 patients who underwent biopsies, a diagnosis was obtained. A total of 5 patients presented non-neoplastic lesions (dermoid tumors or cavernomas). A total of 9 patients harbored low-grade tumors and 6 high-grade tumors. Patients with low-grade tumors and non-neoplastic lesions are all alive with no evidence of disease or stable residue. Four patients affected by high grade tumors died. No patient suffered permanent neurological deficits related to the surgical approach. Three patients presented temporary neurological deficits following the procedure: one case of strabismus, one case of aphasia and hemiparesis, secondary to delayed, transient thrombosis of the Labbé vein, and 1 case of trigeminal neuralgia. CONCLUSION The subtemporal approach represents a feasible approach for mesencephalic and perimesencephalic lesions in children. It provides an ample and direct access, with excellent outcomes and acceptable postoperative morbidity.
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Affiliation(s)
- Pietro Spennato
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Carmela Chiaramonte
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Carmela Russo
- Department of Pediatric Neuroradiology, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Nicola Onorini
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy.,Neurosurgery Unit, University of Brescia, Brescia, Italy
| | - Giuseppe Mirone
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Federica Mazio
- Department of Pediatric Neuroradiology, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Giuliana Di Martino
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | | | - Giuseppe Cinalli
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
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Cavalheiro S, Serrato-Avila JL, Párraga RG, Da Costa MDS, Nicácio JM, Rocha PR, Chaddad-Neto F. Interpeduncular Sulcus Approach to the Posterolateral Pons. World Neurosurg 2020; 138:e795-e805. [PMID: 32217179 DOI: 10.1016/j.wneu.2020.03.084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/15/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In this article, we describe a new safe entry point for the posterolateral pons. METHODS To show the adjacent anatomy and measure the part of the interpeduncular sulcus that can be safely accessed, we first performed a review of the literature regarding the pons anatomy and its surgical approaches. Thereafter, 1 human cadaveric head and 15 (30 sides) human brainstems with attached cerebellums were bilaterally dissected with the fiber microdissection technique. A clinical correlation was made with an illustrative case of a dorsolateral pontine World Health Organization grade I astrocytoma. RESULTS The safe distance for accessing the interpeduncular sulcus was found to extend from the caudal end of the lateral mesencephalic sulcus to the point at which the intrapontine segment of the trigeminal nerve crosses the interpeduncular sulcus. The mean distance was 8.2 mm (range, 7.15-8.85 mm). Our interpeduncular sulcus safe entry zone can be exposed through a paramedian infratentorial supracerebellar approach. When additional exposure is required, the superior portion of the quadrangular lobule of the cerebellar hemispheric tentorial surface can be removed. In the presented case, surgical resection of the tumor was performed achieving a gross total resection, and the patient was discharged without neurologic deficit. CONCLUSIONS The interpeduncular sulcus safe entry zone provides an alternative direct route for treating intrinsic pathologic entities situated in the posterolateral tegmen of the pons between the superior and middle cerebellar peduncles. The surgical corridor provided by this entry point avoids most eloquent neural structures, thereby preventing surgical complications.
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Affiliation(s)
- Sergio Cavalheiro
- Department of Neurosurgery, Pediatric Oncology Institute, Federal University of São Paulo, São Paulo, Brazil
| | | | - Richard Gonzalo Párraga
- Department of Neurosurgery, Neurosurgery Institute of Bolivia (INEB), Cochabamba, Bolivia; Department of Neurological Surgery, Hospital UNIVALLE, Cochabamba, Bolivia
| | - M D S Da Costa
- Department of Neurosurgery, Pediatric Oncology Institute, Federal University of São Paulo, São Paulo, Brazil
| | - Jardel Mendoça Nicácio
- Department of Neurosurgery, Pediatric Oncology Institute, Federal University of São Paulo, São Paulo, Brazil
| | - Paulo Ricardo Rocha
- Department of Morphology and Genetics, Federal University of São Paulo, São Paulo, Brazil
| | - Feres Chaddad-Neto
- Department of Neurosurgery, Vascular Division, Federal University of São Paulo, São Paulo, Brazil; Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
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Xie S, Xiao XR, Li H, Meng GL, Zhang JT, Wu Z, Zhang LW. Surgical treatment of pontine cavernous malformations via subtemporal transtentorial and intradural anterior transpetrosal approaches. Neurosurg Rev 2019; 43:1179-1189. [PMID: 31388841 DOI: 10.1007/s10143-019-01156-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 06/28/2019] [Accepted: 07/29/2019] [Indexed: 11/26/2022]
Abstract
The aim of this study was to report our surgical experience on resection of the pontine cavernous malformations (CMs) via subtemporal transtentorial approach (STTA) and intradural anterior transpetrosal approach (ATPA). Clinical data were retrospectively reviewed in 61 patients with pontine CMs that were surgically treated by the STTA and the intradural ATPA. The surgical procedures, complications, and outcomes were analyzed. The study consists of 61 patients with a total of 61 pontine CMs. Other than 4 lesions located medially in the pons, all CMs were in the lateral pons with a left or right lateral epicenter (the left/right ratio was 22/35). Totally, 11 patients (18.0%) with lesions located in the upper pons were treated by the STTA, and 50 patients (82.0%) with lesions involving the lower pons were treated by the intradural ATPA. Postoperatively, the complete resection was achieved in 58 patients (95.1%) and incomplete resection in 3 patients (4.9%). Twenty-seven patients (44.3%) suffered from a new or worsened neurological deficit in the immediate postoperative period, and 8 patients (13.1%) encountered a non-neural complication, including rebleeding, cerebrospinal fluid leak, intracranial infection, and pulmonary infection, and 3 patients had contusion of temporal lobe. With a mean follow-up of 54.2 months, the patients' neurological condition had improved in 43 cases (71.6%), not changed in 10 cases (16.7%), and worsened in 7 cases (11.7%), respectively. The Karnofsky Performance Scale (KPS) score evaluated at the last time for per patient was significantly better than their baseline status (t = 6.677, p < 0.001). However, 21 patients (35.0%) suffered from a new or worsened persistent postoperative deficit. The lateral and anterolateral pons can be exposed well by the subtemporal transtentorial and intradural anterior transpetrosal approaches. Lesions of CMs located in the lateral pons, including ventrolateral and dorsolateral pons, could be totally removed by these two lateral approaches with an acceptable surgical morbidity.
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Affiliation(s)
- Sungel Xie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xin-Ru Xiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Huan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Guo-Lu Meng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jun-Ting Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhen Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Li-Wei Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
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Spiessberger A, Baumann F, Stauffer A, Marbacher S, Kothbauer KF, Fandino J, Moriggl B. The Subtemporal Approach to the Lateral Midbrain with and without Zygomatic Osteotomy: An Anatomical Study. Clin Anat 2019; 32:710-714. [PMID: 30968458 DOI: 10.1002/ca.23383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/05/2019] [Accepted: 04/08/2019] [Indexed: 11/10/2022]
Abstract
The subtemporal approach provides a narrow operative corridor to the crus cerebrum and adjacent structures of the crural, interpeduncular, and ambient cistern. Addition of a zygomatic osteotomy widens this narrow corridor and spares retraction of the temporal lobe. We investigate and compare the morphometric parameters of the subtemporal approach with versus without zygomatic osteotomy. On each side of four cadaveric heads, a temporal craniotomy was performed to gain access to the crus cerebrum and adjacent subarachnoid cisterns using a subtemporal approach. Operative corridor width and corridor working angle were measured with and without brain retraction on each specimen side. Next, a zygomatic osteotomy was performed followed by full downward reflection of the temporalis muscle and further drilling of the squamous part of the temporal bone. Lastly, operative corridor width and corridor working angle were measured again for comparison. The subtemporal operating corridor was (mean/SD): 5.8/2.6 mm without retraction, 11.4/4.3 mm with retraction, and 13.5/6.5° working angle. After addition of a zygomatic osteotomy, the operative corridor was 8/9.2/4.3 mm without retraction, 14.7/4.5 mm with retraction, 31.8/3.1° working angle. Zygomatic osteotomy significantly increased the operative corridor working angle of the subtemporal approach. Furthermore, we demonstrate a direct approach into the interpeduncular fossa. Clin. Anat. 32:710-714, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Fabian Baumann
- Department of Neurosurgery, Luzerner Kantonsspital, Luzern, Switzerland
| | | | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Karl Friedrich Kothbauer
- Department of Neurosurgery, Luzerner Kantonsspital, Luzern, Switzerland.,Universität Basel, Basel, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Bernhard Moriggl
- Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
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10
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Surgical Management of Brainstem Cavernous Malformation: Report of 67 Patients. World Neurosurg 2019; 122:e1162-e1171. [DOI: 10.1016/j.wneu.2018.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 10/31/2018] [Accepted: 11/02/2018] [Indexed: 11/19/2022]
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11
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Anterior subtemporal approach for severe upper pontine hematomas: A report of 28 surgically treated cases. J Clin Neurosci 2018; 54:20-24. [DOI: 10.1016/j.jocn.2018.04.063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 02/22/2018] [Accepted: 04/22/2018] [Indexed: 11/18/2022]
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Tayebi Meybodi A, Gandhi S, Mascitelli J, Bozkurt B, Bot G, Preul MC, Lawton MT. The oculomotor-tentorial triangle. Part 1: microsurgical anatomy and techniques to enhance exposure. J Neurosurg 2018; 130:1426-1434. [PMID: 29957111 DOI: 10.3171/2018.1.jns173139] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 01/15/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Access to the ventrolateral pontomesencephalic area may be required for resecting cavernous malformations, performing revascularization of the upper posterior circulation, and treating vascular lesions such as aneurysms. However, such access is challenging because of nearby eloquent structures. Commonly used corridors to this surgical area include the optico-carotid, supracarotid, and carotid-oculomotor triangles. However, the window lateral to the oculomotor nerve can also be used and has not been studied. The authors describe the anatomical window formed between the oculomotor nerve and the medial tentorial edge (the oculomotor-tentorial triangle [OTT]) to the ventrolateral pontomesencephalic area, and assess techniques to expand it. METHODS Four cadaveric heads (8 sides) underwent orbitozygomatic craniotomy. The OTT was exposed via a pretemporal approach. The contents of the OTT were determined and their anatomical features were recorded. Also, dimensions of the brainstem surface exposed lateral and inferior to the oculomotor nerve were measured. Measurements were repeated after completing a transcavernous approach (TcA), and after resection of temporal lobe uncus (UnR). RESULTS The s1 segment and proximal s2 segment of the superior cerebellar artery (SCA) and P2A segment of the posterior cerebral artery (PCA) were the main contents of the OTT, with average exposed lengths of 6.4 ± 1.3 mm and 5.5 ± 1.6 mm for the SCA and PCA, respectively. The exposed length of the SCA increased to 9.6 ± 2.7 mm after TcA (p = 0.002), and reached 11.6 ± 2.4 mm following UnR (p = 0.004). The exposed PCA length increased to 6.2 ± 1.6 mm after TcA (p = 0.04), and reached 10.4 ± 1.8 mm following UnR (p < 0.001). The brainstem surface was exposed 7.1 ± 0.5 mm inferior and 5.6 ± 0.9 mm lateral to the oculomotor nerve initially. The exposure inferior to the oculomotor nerve increased to 9.3 ± 1.7 mm after TcA (p = 0.003), and to 9.9 ± 2.5 mm after UnR (p = 0.21). The exposure lateral to the oculomotor nerve increased to 8.0 ± 1.7 mm after TcA (p = 0.001), and to 10.4 ± 2.4 mm after UnR (p = 0.002). CONCLUSIONS The OTT is an anatomical window that provides generous access to the upper ventrolateral pontomesencephalic area, s1- and s2-SCA, and P2A-PCA. This window may be efficiently used to address various pathologies in the region and is considerably expandable by TcA and/or UnR.
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Duan H, Hara Y, Goto T, Chiba A, Hongo K. Giant cavernous malformation in the ventrolateral midbrain with extension into the thalamus: a case report of a paramedian supracerebellar transtentorial approach. Acta Neurochir (Wien) 2016; 158:1533-8. [PMID: 27328840 DOI: 10.1007/s00701-016-2870-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 06/02/2016] [Indexed: 11/26/2022]
Abstract
Cavernous malformations (CMs) of the midbrain and thalamus are relatively rare and particularly difficult to be resected given their location in eloquent tissues. Here, we report a case of a 14-year-old boy who experienced repeated and progressive right hemiparesis. Image examinations showed a gradually enlarged CM originated in the left ventrolateral midbrain extending to the left thalamus with repeated hemorrhage. By performing a paramedian supracerebellar transtentorial approach, the CM was totally removed, and the patient recovered without any new neurological deficit. The authors' experience suggests that this approach is eminent in treating giant lesions involving the ventrolateral midbrain and thalamus.
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Affiliation(s)
- Hongzhou Duan
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
- Department of Neurosurgery, Peking University First Hospital, Xicheng District, Beijing, China
| | - Yosuke Hara
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Tetsuya Goto
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.
| | - Akihiro Chiba
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Kazuhiro Hongo
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
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Matsushima K, Yagmurlu K, Kohno M, Rhoton AL. Anatomy and approaches along the cerebellar-brainstem fissures. J Neurosurg 2015; 124:248-63. [PMID: 26274986 DOI: 10.3171/2015.2.jns142707] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Fissure dissection is routinely used in the supratentorial region to access deeply situated pathology while minimizing division of neural tissue. Use of fissure dissection is also practical in the posterior fossa. In this study, the microsurgical anatomy of the 3 cerebellar-brainstem fissures (cerebellomesencephalic, cerebellopontine, and cerebellomedullary) and the various procedures exposing these fissures in brainstem surgery were examined. METHODS Seven cadaveric heads were examined with a microsurgical technique and 3 with fiber dissection to clarify the anatomy of the cerebellar-brainstem and adjacent cerebellar fissures, in which the major vessels and neural structures are located. Several approaches directed along the cerebellar surfaces and fissures, including the supracerebellar infratentorial, occipital transtentorial, retrosigmoid, and midline suboccipital approaches, were examined. The 3 heads examined using fiber dissection defined the anatomy of the cerebellar peduncles coursing in the depths of these fissures. RESULTS Dissections directed along the cerebellar-brainstem and cerebellar fissures provided access to the posterior and posterolateral midbrain and upper pons, lateral pons, floor and lateral wall of the fourth ventricle, and dorsal and lateral medulla. CONCLUSIONS Opening the cerebellar-brainstem and adjacent cerebellar fissures provided access to the brainstem surface hidden by the cerebellum, while minimizing division of neural tissue. Most of the major cerebellar arteries, veins, and vital neural structures are located in or near these fissures and can be accessed through them.
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Affiliation(s)
- Ken Matsushima
- Department of Neurological Surgery, University of Florida, Gainesville, Florida; and.,Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Kaan Yagmurlu
- Department of Neurological Surgery, University of Florida, Gainesville, Florida; and
| | - Michihiro Kohno
- Department of Neurosurgery, Tokyo Medical University, Tokyo, Japan
| | - Albert L Rhoton
- Department of Neurological Surgery, University of Florida, Gainesville, Florida; and
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Salunke P, Sahoo S, Futane S. Successful excision of a pontomesencephalic cavernoma through anterior subtemporal route without mapping: Anatomical landmarks as a road map. Surg Neurol Int 2014; 5:15. [PMID: 24678431 PMCID: PMC3942592 DOI: 10.4103/2152-7806.126044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 09/19/2013] [Indexed: 11/04/2022] Open
Affiliation(s)
- Pravin Salunke
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sushant Sahoo
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sameer Futane
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Prediction of outcomes for brainstem cavernous malformation. Clin Neurol Neurosurg 2013; 115:2117-23. [DOI: 10.1016/j.clineuro.2013.07.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 06/29/2013] [Accepted: 07/28/2013] [Indexed: 11/18/2022]
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Li D, Yang Y, Hao SY, Wang L, Tang J, Xiao XR, Zhou H, Jia GJ, Wu Z, Zhang LW, Zhang JT. Hemorrhage risk, surgical management, and functional outcome of brainstem cavernous malformations. J Neurosurg 2013; 119:996-1008. [PMID: 23952884 DOI: 10.3171/2013.7.jns13462] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [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 evaluate the pre- and postoperative rehemorrhage risk, neurological function outcome, and prognostic factors of surgically treated brainstem cavernous malformations (CMs) with long-term follow-up. METHODS The authors conducted a retrospective review of the clinical data from 242 patients with brainstem CMs that were surgically treated between 1999 and 2010. Patient charts, imaging findings, and outcomes were examined. RESULTS The study included 242 patients, with a male-to-female ratio of 1.3 and mean age of 32.6 years. The mean modified Rankin Scale scores on admission, at discharge, at 3 and 6 months after surgery, and at recent evaluation were 2.2, 2.6, 2.3, 1.8, and 1.5, respectively. The preoperative calculated annual hemorrhage and rehemorrhage rates were 5.0% and 60.9%, respectively. The complete resection rate was 95%. Surgical morbidity occurred in 112 patients (46.3%). Eighty-five patients (35.1%) demonstrated worsened condition immediately after surgery; 34 (41.0%) and 51 (61.4%) of these patients recovered to their baseline level within 3 and 6 months after surgery, respectively. At a mean follow-up of 89.4 months, the patients' condition had improved in 147 cases (60.7%), was unchanged in 70 cases (28.9%), and had worsened in 25 cases (10.3%). A total of 8 hemorrhages occurred in 6 patients, and the postoperative annual hemorrhage rate was 0.4%. Permanent morbidity remained in 65 patients (26.9%). The adverse factors for preoperative rehemorrhage were age ≥ 50 years, size ≥ 2 cm, and perilesional edema. The risk factors for postoperative hemorrhage were developmental venous anomaly and incomplete resection. The independent adverse factors for long-term outcome were increased age, multiple hemorrhages, ventral-seated lesions, and poor preoperative status. Favorable, complete improvement in the postoperative deficits over time was correlated with good preoperative neurological function and continuing improvement thereafter. CONCLUSIONS Favorable long-term outcomes and significantly low postoperative annual hemorrhage rates were achieved via surgery. Total resection should be attempted with an aim of minimal injury to neurological function; however, postoperative deficits can improve during the postoperative course. Close follow-up with radiological examination is proposed for patients with adverse factors predictive of rehemorrhage.
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Affiliation(s)
- Da Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing
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Hu P, Liang J, Bao Y, Li M, Ling F. The pterional transsylvian transtentorial approach to ventrolateral pontine cavernomas: indications and techniques. World Neurosurg 2013; 82:1276-82. [PMID: 23851214 DOI: 10.1016/j.wneu.2013.06.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Accepted: 06/28/2013] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The authors describe a pterional transsylvian transtentorial approach to the ventrolateral pons based on its clinical application to cavernomas. METHODS Consecutive patients in their database with brain stem cavernomas who underwent surgical removal from April 2009 to December 2012 were retrospectively analyzed. Four patients who underwent anterolateral pontine cavernoma removal via the pterional transsylvian transtentorial approach were included in the current study. The surgical indications, techniques, exposure, and feasibility were analyzed. To make a comprehensive illustration of surgical feasibility and exposure, a fresh, colored-latex-injected cadaveric head specimen was used. RESULTS The cavernomas of these four patients were confirmed successful removal by both surgeon's intraoperative views and follow-up magnetic resonance images. Cranial nerve (CN) IV was inadvertently transected in one patient, and transient muscle power decrease occurred in another patient. Based on the surgeons' experiences and anatomy illustration, the pterional transsylvian transtentorial approach enables a wide exposure of the upper ventral pons inferolaterally to the CN V root entry zone, inferiorly to the CN V root entry zone horizontal level, and medially to the basilar artery. CONCLUSION Although a comprehensive comparison with other approaches needs a large patient volume and a prospective designed study, the pterional transsylvian transtentorial approach could be an alternative for ventrolateral pontine cavernomas. The principle for this approach to ventrolateral pontine cavernomas is that if the thinnest parenchyma layer over the cavernoma could be defined in the ipsilateral upper ventrolateral pons, facilitated by an oblique multiangled working space, cavernomas in even the entire ventrolateral pons could be removed.
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Affiliation(s)
- Peng Hu
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, People's Republic of China
| | - Jiantao Liang
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, People's Republic of China
| | - Yuhai Bao
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, People's Republic of China.
| | - Mingchu Li
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, People's Republic of China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, Beijing, People's Republic of China
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Brainstem Cavernous Malformations: 1390 Surgical Cases from the Literature. World Neurosurg 2013; 80:89-93. [DOI: 10.1016/j.wneu.2012.04.002] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 04/03/2012] [Indexed: 11/23/2022]
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Sabatino G, Rigante L, Marchese E, Albanese A, Esposito G, Capone G, Maira G. Anterior subtemporal approach for posterolateral brainstem cavernomas: report of ten cases. Acta Neurochir (Wien) 2012; 154:2009-16. [PMID: 22961242 DOI: 10.1007/s00701-012-1496-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 08/22/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND The neuronavigation-assisted anterior subtemporal approach is proposed in this article as an alternative to surgery of posterolateral brainstem cavernomas. Brainstem cavernomas represent a neurosurgical challenge because of the high morbidity and mortality rate related to their surgical removal. Several nerve nuclei, ascending and descending fibers make this region at high risk of serious postoperative deficits. METHODS Between 1998 and 2010, 24 patients underwent surgical removal of brainstem cavernomas in our institution. Ten of these patients presented a cavernous malformation in the posterolateral region of the brainstem and underwent surgical removal by means of a neuronavigation-assisted anterior subtemporal approach. RESULTS Lesion removal was complete for all patients. There were no cases of surgery-related death. Neurological status improved or remained unchanged after surgery in all cases. All patients presented good outcomes at 12 to 154 months' follow-up (mean 70 months; GOS = 5 in 8/10 patients, 4 in 2/10 patients; mRS = 0-1 in all patients). Only one patient presented transient confusion, aphasia and seizures related to temporal lobe swelling, which resolved completely within a few days. One patient developed cranial nerve III palsy and left hemiparesis with gradual recovery. CONCLUSIONS This approach represents a valid alternative to the "more classical" approaches for the surgery of posterolateral cavernomas of the pontomesenchephalic junction reaching the tentorial incisura, reducing the risk of damaging the vein of Labbé, temporal lobe swelling, cerebellar swelling, ophtalmoparesis, fourth ventricle cranial nerve nuclei lesions. Skeletonization of sigmoidal sinus provides with good outcomes, low morbidity and mortality.
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