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Alexander AY, Leonel LCPC, Agosti E, Celda MP, Lanzino G. The precuneal interhemispheric, trans-tentorial corridor to the pineal region and brainstem, surgical anatomy, and case illustration. Acta Neurochir (Wien) 2022; 164:1095-1103. [PMID: 35266050 DOI: 10.1007/s00701-022-05167-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/19/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The pineal region and dorsal midbrain are among the most challenging surgical targets. To approach lesions in this region that harbor a superior to inferior long axis, we describe the basic steps of the precuneal, interhemispheric, trans-tentorial approach and illustrate anatomical landmarks of this established, but not so popular, surgical trajectory. METHOD To study the anatomical landmarks and safety of this approach, the neurovascular anatomy was studied on 22 sides of 11 formalin-fixed latex-injected anatomical specimens. A step-by-step dissection of the precuneal interhemispheric trans-tentorial approach and study of the key anatomical landmarks was performed. An illustrative clinical case of a pontomesencephalic cavernous malformation (CM) resected through this approach is also detailed. RESULTS The mean distance from the transverse sinus to the most posterior cortical vein draining into the superior sagittal sinus was 6.4 cm. The mean distance from the calcarine sulcus to the most posterior cortical vein was 5.3 cm. Key steps of the dissection are as follows: craniotomy exposing the posterior aspect of the superior sagittal sinus (SSS), durotomy and gentle retraction of the SSS edge, dissection of the interhemispheric fissure, linear incision of the tentorium that extends anteriorly to the incisura and lateral reflection of the tentorium, and arachnoidal dissection and exposure of the cerebellomesencephalic fissure. CONCLUSION The precuneal, interhemispheric, trans-tentorial approach affords excellent access to the falcotentorial junction, splenium, pineal region, quadrigeminal cistern, and dorsal pons once the cerebellomesencephalic fissure has been dissected.
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Affiliation(s)
- A Yohan Alexander
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Luciano C P C Leonel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Edoardo Agosti
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Maria Peris Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Giuseppe Lanzino
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA.
- Department of Neurological Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
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Wong AK, Vasenina V, Wong RH. Keyhole Superior Interhemispheric Approach to Midline Meningiomas of the Far Frontal Region of the Anterior Skull Base: Cadaveric Study and Illustrative Cases. World Neurosurg 2021; 151:70-76. [PMID: 33878464 DOI: 10.1016/j.wneu.2021.04.036] [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: 02/11/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Unique challenges can present in the treatment of small to mid-sized meningiomas that arise from the region of the anterior most aspect of the falx cerebri including its junction with the anterior skull base, what we call the far frontal region. Although this region of the anterior skull base is considered in the surgical approach of olfactory groove meningiomas invading this space, important differences exist between these tumors and those of the far frontal region. METHODS Toward refining surgical selection, our cadaveric study details a minimally invasive keyhole superior interhemispheric approach to the far frontal region and 2 illustrative cases show the feasibility of this approach. RESULTS Our cadaveric study defines 5 steps of the approach from the incision, craniectomy, dural opening, approaching the skull base and ipsilateral exposure, and finally falcine resection and bilateral skull base exposure. Two illustrative cases with the approach confirmed visualization of the full extent of tumor and gross total resection with preservation of the unaffected olfactory bulb. CONCLUSIONS To the best of our knowledge, our anatomic study is distinctively unique in quantifying the working distance of the keyhole superior interhemispheric exposure and refining visualization of the far frontal region. We discuss these benefits and limitations (i.e., substantial involvement of tumor beyond midline) and differences with large meningiomas of the olfactory groove and far frontal region with significant posterior or lateral extension for which conventional exposures are appropriate.
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Affiliation(s)
- Andrew K Wong
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Valentina Vasenina
- Department of Neurosurgery, University of Chicago, Chicago, Illinois, USA
| | - Ricky H Wong
- Department of Neurosurgery, NorthShore University Health System, Evanston, Illinois, USA.
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