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Alexander AY, Agosti E, Leonel LCPC, Lanzino G, Peris-Celda M. Comparison Between the Supracerebellar Infratentorial and Precuneal Interhemispheric, Transtentorial Approaches to the Cerebellomesencephalic Fissure: An Anatomoradiological Study and Illustrative Cases. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00658. [PMID: 36972426 DOI: 10.1227/ons.0000000000000684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/17/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND The dorsal brainstem and cerebellomesencephalic fissure are challenging surgical targets. To afford a preferentially craniocaudal trajectory to this region, the precuneal interhemispheric transtentorial approach (PCIT) has been proposed. OBJECTIVE To didactically describe and compare exposures and anatomic indications of the supracerebellar infratentorial approach (SCIT) and PCIT to the cerebellomesencephalic fissure. METHODS Nine formalin-fixed, latex-injected cadaveric head specimens were used to perform a midline SCIT and bilateral PCITs and measure the distance of each approach. Twenty-four formalin-fixed specimens were used to measure the distance from the most posterior cortical bridging vein entering the superior sagittal sinus to the calcarine sulcus and the torcula. Fifty-one magnetic resonance images were reviewed to calculate the angle of each approach. Three illustrative surgical cases were described. RESULTS Mean distances from the brain or cerebellar surface to the operative target of the PCIT and SCIT were 7.1 cm (range: 5-7.7 cm) and 5.5 cm (range: 3.8-6.2 cm), respectively. The SCIT provided direct access to structures of the quadrigeminal cistern bilaterally. The PCIT provided access from the ipsilateral inferior colliculus to the ipsilateral infratrochlear zone. The PCIT's benefit was the direct access it provided to the cerebellomesencephalic fissure because of its superior to inferior trajectory. CONCLUSION The PCIT is indicated for unilateral lesions of the cerebellomesencephalic fissure and dorsal brainstem that harbor a craniocaudal long axis and do not have a superior extension beyond the superior colliculi. The SCIT is beneficial for lesions that extend bilaterally, have an anteroposterior long axis, or involve the Galenic complex.
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Affiliation(s)
- A Yohan Alexander
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - Edoardo Agosti
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luciano C P C Leonel
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Giuseppe Lanzino
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria Peris-Celda
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota, USA
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Teton ZE, Hendricks BK, Marotta DA, Cohen-Gadol A. Transtentorial Approach to Parahippocampal Lesions: A Technically Challenging Approach for Preserving Temporal Lobe Structures. World Neurosurg 2020; 142:626-635. [PMID: 32987618 DOI: 10.1016/j.wneu.2020.07.092] [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: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 11/29/2022]
Abstract
In this installment of the Neurosurgical Atlas Series for WORLD NEUROSURGERY, the authors examine the paramedian supracerebellar transtentorial (SCTT) approach as a means of accessing the basal posteromedial temporal lobe for both intradural and extradural lesions. While other approaches, such as the subtemporal, transtemporal, and transsylvian routes, are often used to reach this otherwise impervious region, all of them do so at the expense of supratentorial structural integrity. Despite the long and narrow working distance provided by the SCTT approach, the access it provides to critical, deep-seated regions with little to no associated morbidity makes it our preferred approach in these patients. In this work, we highlight the perioperative considerations for this procedure, discuss the technical nuances of all aspects of the operation, and provide discussion on the approach in the context of its evolution and alternatives.
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Affiliation(s)
- Zoe E Teton
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA; The Neurosurgical Atlas, Indianapolis, Indiana, USA
| | | | - Dario A Marotta
- Alabama College of Osteopathic Medicine, Dothan, Alabama, USA; Division of Neuropsychology, Department of Neurology, University of Alabama, Birmingham, Alabama, USA
| | - Aaron Cohen-Gadol
- The Neurosurgical Atlas, Indianapolis, Indiana, USA; Department of Neurosurgery, Indiana University, Indianapolis, Indiana, USA.
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Awake Craniotomy for a Left Pan-Hippocampal Diffuse Low-Grade Glioma in a Deaf and Mute Patient Using Sign Language. World Neurosurg 2019; 134:629-634.e1. [PMID: 31790835 DOI: 10.1016/j.wneu.2019.11.129] [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: 11/01/2019] [Revised: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Awake craniotomy is becoming an essential technique, especially for intrinsic brain tumors which have no clear margins and where extent of resection (EOR) matters. However, intraoperative monitoring for awaken patients requires voice feedback in regular settings. Resection of hippocampal glioma is challenging because of its deep-seated location, its extension in an anterior-posterior axis, and being covered with eloquent cortex. We present a native deaf and mute patient, who has been diagnosed of a left pan-hippocampal glioma, who underwent an awake craniotomy using sign language during intraoperative monitoring. CASE DESCRIPTION The patient was a 58-year-old, right-handed, native deaf and mute woman who was diagnosed with a left pan-hippocampal glioma. Magnetic resonance imaging (MRI) revealed an intrinsic, nonenhanced, expansile lesion involving the pan-hippocampus. Functional MRI preferred a right hemisphere-dominant pattern. Neuropsychologic testing was normal. An awake craniotomy was successfully performed using sign language to preserve her remaining sole method of communication. A standard sleep-awake-sleep protocol with a transmiddle temporal gyrus (2.5 × 1 cm gyrectomy) approach was performed after a negative mapping result. More than 90% EOR was achieved with only a 0.7 cm3 residual tumor at the hippocampal tail. The pathology was anaplastic ganglioglioma, Ki-67 70%, and World Health Organization grade III. Her postoperative neuropsychologic status was the same as preoperative condition. CONCLUSIONS We demonstrated using sign language for intraoperative monitoring is feasible in a native deaf and mute patient. We also showed a navigation-assisted minimal transcortical approach to achieve >90% EOR for a pan-hippocampal glioma in a single-stage operation.
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Innovations in the Art of Microneurosurgery for Reaching Deep-Seated Cerebral Lesions. World Neurosurg 2019; 131:321-327. [PMID: 31284052 DOI: 10.1016/j.wneu.2019.06.210] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 06/25/2019] [Accepted: 06/26/2019] [Indexed: 11/22/2022]
Abstract
Deep-seated cerebral lesions have fascinated and frustrated countless surgical innovators since the dawn of the microneurosurgical era. To determine the optimal approach, the microneurosurgeon must take into account the characteristics and location of the pathological lesion as well as the operator's range of technical expertise. Increasingly, microneurosurgeons must select between multiple operative corridors that can provide access to the surgical target. Innovative trajectories have emerged for many indications that provide more flexible operative angles and superior exposure but result in longer working distances and more technically demanding maneuvers. In this article, we highlight 4 innovative surgical corridors and compare their strengths and weaknesses against those of more conventional approaches. Our goal is to use these examples to illustrate the following principles of microneurosurgical innovation: (1) discover more efficient and flexible exposures with superior working angles; (2) ensure maximal early protection of critical neurovascular structures; and (3) effectively handle target pathology with minimal disruption of normal tissues.
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Golub D, Mehan ND, Kwan K, Salas SJ, Schulder M. Supracerebellar Transtentorial Approach for Occipital Meningioma to Maximize Visual Preservation: Technical Note. Oper Neurosurg (Hagerstown) 2018; 17:E177-E183. [DOI: 10.1093/ons/opy380] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 11/18/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE
Surgery for resection of tentorial meningiomas compressing primary visual cortex carries a significant risk of worsening vision. This concern is especially acute in patients with a preexisting visual deficit. Approaches that involve mechanical retraction of the occipital lobe further threaten visual function. The supracerebellar transtentorial (SCTT) approach, which does not carry a risk of occipital retraction injury, should be considered for patients with occipital tentorial meningiomas to maximize functional visual outcomes.
CLINICAL PRESENTATION
A 54-yr-old woman underwent 2 resections and radiation therapy for a right occipital oligodendroglioma as a teenager. She was left with a complete left homonymous hemianopsia. The patient now presented with progressive vision loss in her remaining right visual field. Imaging revealed a left occipital superiorly projecting tentorial meningioma. To preserve her remaining visual function the SCTT approach was chosen for resection. A Simpson grade 1 removal was achieved without disrupting the occipital lobe pia or requiring mechanical cerebellar retraction. A diagnosis of a WHO grade II meningioma (presumably radiation induced) was made. The patient's vision returned to premorbid baseline 1 wk after surgery.
CONCLUSION
The SCTT approach should be considered for the surgical management of patients with occipital tentorial meningiomas when visual preservation is at risk. This approach avoids transgression of visual cortex and minimizes the risk of venous infarction or contusions from retraction injury.
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Affiliation(s)
- Danielle Golub
- Department of Neurosurgery, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
- Department of Neurosurgery, Department of Neurology, New York University School of Medicine, New York, New York
| | - Neal D Mehan
- Department of Neurosurgery, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Kevin Kwan
- Department of Neurosurgery, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Sussan J Salas
- Department of Neurosurgery, Henry Ford Hospital System, Detroit, Michigan
| | - Michael Schulder
- Department of Neurosurgery, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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Altay T, Akkurt C. Combined Retrosigmoid-paramedian Supracerebellar Transtentorial Approach as an Alternative to Classical Transtemporal Approaches: A Technical Note. Asian J Neurosurg 2018; 13:161-164. [PMID: 29492152 PMCID: PMC5820877 DOI: 10.4103/1793-5482.185062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Epidermoid tumors are rare benign neoplasms. They commonly occur in the parasellar region and the cerebellopontine angle but may sometimes present in the so-called petroclival region, or beyond the boundaries of this location. For those that are localized in multiple compartments, staged surgeries, extensive transtemporal approaches, or somewhat limited extended middle fossa approach are generally performed. Although a good resection can be achieved by these approaches, they carry relatively high morbidity and mortality. We report a case of epidermoid tumor with infra- and supratentorial extensions, and propose a combined retrosigmoid-paramedian supracerebellar transtentorial approach as an alternative to classical transtemporal approaches.
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Affiliation(s)
- Tamer Altay
- Neurosurgery Clinic, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Cem Akkurt
- Neurosurgery Clinic, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
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Chau AMT, Gagliardi F, Smith A, Pelzer NR, Stewart F, Mortini P, Elbabaa SK, Caputy AJ, Gragnaniello C. The paramedian supracerebellar transtentorial approach to the posterior fusiform gyrus. Acta Neurochir (Wien) 2016; 158:2149-2154. [PMID: 27677522 DOI: 10.1007/s00701-016-2960-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 09/07/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND The posterior fusiform gyrus lies in a surgically challenging region. Several approaches have been described to access this anatomical area. The paramedian supracerebellar transtentorial (SCTT) approach benefits from minimal disruption of normal neurovascular tissue. The aim of this study was to demonstrate its application to access the posterior fusiform gyrus. METHODS Three brains and six cadaveric heads were examined. A stepwise dissection of the SCTT approach to the posterior fusiform gyrus was performed. Local cortical anatomy was studied. The operability score was applied for comparative analysis on surgical anatomy. RESULTS The major posterior landmark used to identify the fusiform gyrus with respect to the medial occipitotemporal gyrus was the collateral sulcus, which commonly bifurcated at its caudal extent. Compared with other surgical approaches addressed to access the region, SCTT demonstrated the best operability in terms of maneuverability arc. Favorable tentorial anatomy is the only limiting factor. CONCLUSIONS The supracerebellar transtentorial approach is able to provide access to the posterior fusiform gyrus via a minimally disruptive, anatomic, microsurgical corridor.
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Affiliation(s)
- Anthony M T Chau
- Macquarie Neurosurgery, Australian School of Advanced Medicine, Macquarie University Hospital, Sydney, Australia
- School of Medicine, University of New England, Armidale, Australia
| | - Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy.
| | - Adam Smith
- School of Medicine, University of New England, Armidale, Australia
| | | | - Fiona Stewart
- School of Medicine, University of New England, Armidale, Australia
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy
| | - Samer K Elbabaa
- Department of Neurological Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Anthony J Caputy
- Department of Neurosurgery, George Washington University, Washington, DC, USA
| | - Cristian Gragnaniello
- Macquarie Neurosurgery, Australian School of Advanced Medicine, Macquarie University Hospital, Sydney, Australia
- School of Medicine, University of New England, Armidale, Australia
- Department of Neurosurgery, George Washington University, Washington, DC, USA
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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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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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Kulwin C, Matsushima K, Malekpour M, Cohen-Gadol AA. Lateral supracerebellar infratentorial approach for microsurgical resection of large midline pineal region tumors: techniques to expand the operative corridor. J Neurosurg 2015; 124:269-76. [PMID: 26275000 DOI: 10.3171/2015.2.jns142088] [Citation(s) in RCA: 16] [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
Pineal region tumors pose certain challenges in regard to their resection: a deep surgical field, associated critical surrounding neurovascular structures, and narrow operative working corridor due to obstruction by the apex of the culmen. The authors describe a lateral supracerebellar infratentorial approach that was successfully used in the treatment of 10 large (> 3 cm) midline pineal region tumors. The patients were placed in a modified lateral decubitus position. A small lateral suboccipital craniotomy exposed the transverse sinus. Tentorial retraction sutures were used to gently rotate and elevate the transverse sinus to expand the lateral supracerebellar operative corridor. This approach placed only unilateral normal structures at risk and minimized vermian venous sacrifice. The surgeon achieved generous exposure of the caudal midline mesencephalon through a "cross-court" oblique trajectory, while avoiding excessive retraction on the culmen. All patients underwent the lateral approach with no approach-related complication. The final pathological diagnoses were consistent with meningioma in 3 cases, pilocytic astrocytoma in 3 cases, intermediate grade pineal region tumor in 2 cases, and pineoblastoma in 2 cases. The entire extent of these tumors was readily reachable through the lateral supracerebellar route. Gross-total resection was achieved in 8 (80%) of the 10 cases; in 2 cases (20%) near-total resection was performed due to adherence of these tumors to deep diencephalic veins. Large midline pineal region tumors can be removed through a unilateral paramedian suboccipital craniotomy. This approach is simple, may spare some of the midline vermian bridging veins, and may be potentially less invasive and more efficient.
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Affiliation(s)
- Charles Kulwin
- Goodman Campbell Brain and Spine, Indiana University Department of Neurological Surgery, Indianapolis, Indiana; and
| | - Ken Matsushima
- Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Mahdi Malekpour
- Goodman Campbell Brain and Spine, Indiana University Department of Neurological Surgery, Indianapolis, Indiana; and
| | - Aaron A Cohen-Gadol
- Goodman Campbell Brain and Spine, Indiana University Department of Neurological Surgery, Indianapolis, Indiana; and
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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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Marcus HJ, Sarkar H, Mindermann T, Reisch R. Keyhole supracerebellar transtentorial transcollateral sulcus approach to the lateral ventricle. Neurosurgery 2014; 73:onsE295-301; discussion onsE301. [PMID: 23624413 DOI: 10.1227/01.neu.0000430294.16175.20] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Meningiomas of the lateral ventricles are commonly located in the atria. Surgical access to such tumors is challenging because of their deep location and proximity to critical neurovascular structures, particularly if situated on the dominant side. Although a number of approaches have been described in the literature, most carry the risk of postoperative neuropsychological, visual, or speech deficits, especially when operating on the dominant hemisphere. The supracerebellar transtentorial transcollateral sulcus (STTCS) approach offers the potential to circumvent functionally important structures, reducing the risk of these approach-related neurological deficits. CLINICAL PRESENTATION Two patients with dominant hemisphere trigonal meningiomas underwent surgical resection with the use of the STTCS approach. Neuronavigation was used to carefully plan the incision, craniotomy, and exposure, and also intraoperatively to orientate the operating surgeon at key steps, particularly when raising the tentorial flap in line with the tumor. Endoscopy was used to provide increased light intensity, an extended viewing angle, and higher magnification in comparison with a microscope. Specially designed tube-shaft instruments were also used to assist with manipulation through the narrow surgical corridor. In both cases, the tumors were fully resected without approach-related morbidity. CONCLUSION The STTCS approach provides good access to tumors located in the trigonal region, reducing the risk of iatrogenic language or visual field deficits. In dominant hemisphere lesions, in the hands of an experienced neurosurgeon, the STTCS approach is an effective alternative to existing techniques.
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Affiliation(s)
- Hani J Marcus
- *Centre for Endoscopic and Minimally Invasive Neurosurgery, Clinic Hirslanden, Zurich, Switzerland; ‡Imperial College London, United Kingdom; §Apollo Specialty Hospital, Chennai, India
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Ansari SF, Young RL, Bohnstedt BN, Cohen-Gadol AA. The extended supracerebellar transtentorial approach for resection of medial tentorial meningiomas. Surg Neurol Int 2014; 5:35. [PMID: 24778923 PMCID: PMC3994713 DOI: 10.4103/2152-7806.128918] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 10/24/2013] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The supracerebellar transtentorial (SCTT) approach has been established as a safe corridor to access the posteriomedial basal temporal region. Previous reports have demonstrated the efficacy of this route in the resection of intrinsic tumors and small arteriovenous malformations. Only one report in the English literature has described its use to resect a medial tentorial meningioma. METHODS The authors discuss the relevant surgical anatomy of this approach and its advantages compared with more traditional routes, and illustrate its application to remove medial tentorial meningiomas through two operative cases with accompanying videos. RESULTS In illustrative case one, the patient recovered from surgery with no deficits. All his preoperative symptoms had resolved at 3-month follow-up. At the 4-year follow-up, MRI did not demonstrate any growth of the residual tumor. In case two, gross total resection was achieved and the patient did not suffer any postoperative language or visual deficit. At 2-year follow-up, no tumor recurrence was present. CONCLUSION The SCTT approach has a potential to safely access extra-axial lesions located around the medial tentorial incisura. As demonstrated in these two cases, the approach merits consideration in patients with tentorial meningiomas as an alternative to more widely utilized skull base approaches and subtemporal routes.
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Affiliation(s)
- Shaheryar F Ansari
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ronald L Young
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Bradley N Bohnstedt
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Aaron A Cohen-Gadol
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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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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de Oliveira JG, Lekovic GP, Safavi-Abbasi S, Reis CV, Hanel RA, Porter RW, Preul MC, Spetzler RF. Supracerebellar Infratentorial Approach to Cavernous Malformations of the Brainstem. Neurosurgery 2010; 66:389-99. [PMID: 20042987 DOI: 10.1227/01.neu.0000363702.67016.5d] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
The supracerebellar infratentorial (SCIT) approach can be performed at the midline (median variant), lateral to the midline (paramedian variant), or at the level of the angle formed by the transverse and sigmoid sinuses (extreme lateral variant). We analyzed our experience with SCIT approaches for the surgical treatment of cavernous malformations of the brainstem (CMBs).
METHODS
Demographic, clinical, radiologic, and surgical data from 45 patients (20 males and 25 females; mean age, 36.2 years) with CMBs surgically removed through SCIT approaches were reviewed retrospectively. Anatomic information was explored using cadaver head dissection.
RESULTS
Twenty-three lesions were in the midbrain, 3 were at the midbrain and extended to the thalamus, 9 were at the pontomesencephalic junction, and 10 were in the upper pons. All patients presented with hemorrhage. The median variant was used in 13 patients, the paramedian variant in 9, and the extreme lateral variant in 23. Intraoperatively, all CMBs were associated with a developmental venous anomaly. At last follow-up, 88% of the patients were the same or better. After a mean follow-up of 20 months, their mean Glasgow Outcome Scale score was 4.1.
CONCLUSION
SCIT approaches provide excellent exposure to CMBs located at the posterior incisural space, not only in the midline but also in the posterolateral surface of the upper pons and midbrain. Careful preoperative planning and neuronavigational assistance are needed to determine the best angle of attack and trajectory for SCIT approaches. Refined microsurgical techniques are paramount to achieve safe surgical removal of CMBs with good outcomes.
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Affiliation(s)
- Jean G. de Oliveira
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona (de Oliveira) (Lekovic) (Safavi-Abbasi) (Reis) (Hanel) (Porter) (Spetzler)
| | - Gregory P. Lekovic
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona (de Oliveira) (Lekovic) (Safavi-Abbasi) (Reis) (Hanel) (Porter) (Spetzler)
| | - Sam Safavi-Abbasi
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona (de Oliveira) (Lekovic) (Safavi-Abbasi) (Reis) (Hanel) (Porter) (Spetzler)
| | - Cassius V. Reis
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona (de Oliveira) (Lekovic) (Safavi-Abbasi) (Reis) (Hanel) (Porter) (Spetzler)
| | - Ricardo A. Hanel
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona (de Oliveira) (Lekovic) (Safavi-Abbasi) (Reis) (Hanel) (Porter) (Spetzler)
| | - Randall W. Porter
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona (de Oliveira) (Lekovic) (Safavi-Abbasi) (Reis) (Hanel) (Porter) (Spetzler)
| | - Mark C. Preul
- Division of Neurological Surgery, and Neurosurgery Research Laboratory, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona (Preul)
| | - Robert F. Spetzler
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona (de Oliveira) (Lekovic) (Safavi-Abbasi) (Reis) (Hanel) (Porter) (Spetzler)
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Uribe JS, Vale FL. Limited access inferior temporal gyrus approach to mesial basal temporal lobe tumors. J Neurosurg 2009; 110:137-46. [DOI: 10.3171/2008.4.17508] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In this retrospective review, the authors examine the clinical characteristics, diagnosis, and outcome of surgery in 25 consecutive patients with mesial basal temporal lobe (MBTL) tumors. A limited access approach to the inferior temporal gyrus (ITG) was used.
Methods
Patients with MBTL tumors were identified from the epilepsy and tumor surgery database at the authors' institution. Intraaxial tumors localized to the mesial basal structures, and without involvement of the cortical surface of the temporal lobe, temporal stem, and basal ganglia were included. Preoperative and postoperative MR images were obtained in all patients. The mean follow-up period was 24 months (range 9–36 months). Preoperative symptoms, neurological deficits, outcomes, surgical complications, and a technical description of the approach are discussed.
Results
Intraaxial MBTL tumors in 25 patients (mean age 44 years, range 8–76 years) were resected using a limited access approach via the ITG. The largest groups of tumors were high-grade gliomas and dysembryoblastic neuroepithelial tumors (8 in each group), followed by oligodendrogliomas, cerebral metastases, and gangliogliomas. Seizures, headaches, and disorientation were the most common preoperative symptoms. Postoperative MR images demonstrated gross-total resection in all cases. There were 2 surgical complications (a superficial wound infection and a transient frontalis branch palsy). There were no permanent neurological complications or significant new hemianoptic defects.
Conclusions
A limited access ITG approach performed with intraoperative image guidance offers an alternative corridor for resection of MBTL tumors (Schramm Type A). This approach may be technically less demanding than the transsylvian or subtemporal approach. Gross-total resection is feasible utilizing this approach and compares favorably with other, more classical approaches.
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Moftakhar R, Izci Y, Basşkaya MK. Microsurgical Anatomy of the Supracerebellar Transtentorial Approach to the Posterior Mediobasal Temporal Region: Technical Considerations With a Case Illustration. Oper Neurosurg (Hagerstown) 2008; 62:1-7; discussion 7-8. [DOI: 10.1227/01.neu.0000317367.61899.65] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Objective:
Surgical access to the posterior portion of the mediobasal temporal lobe presents a formidable challenge to neurosurgeons, and much controversy still exists regarding the selection of the surgical approach to this region. The supracerebellar transtentorial (SCTT) approach to the posterior mediobasal temporal region can be used as an alternative to the subtemporal or transtemporal approaches. The aim of this study was to demonstrate the surgical anatomy of the SCTT approach and review the gyral, sulcal, and vascular anatomy of the posterior mediobasal temporal lobe. The use of this approach in the resection of a ganglioglioma located in the left posterior parahippocam-pal gyrus is illustrated.
Methods:
The SCTT approach to the posterior parahippocampal gyrus was performed on three silicone-injected cadaveric heads. The gyral, sulcal, and arterial anatomy of the posterior mediobasal temporal lobe was studied in six formalin-fixed injected hemispheres.
Results:
The SCTT approach provided a direct path to the posterior mediobasal temporal lobe and exposed the posterior parahippocampal gyrus as well as the adjacent gyri in all of the cadaveric specimens. Through this approach, gross total resection of the ganglioglioma was possible in our patient.
Conclusion:
The SCTT approach provided a viable surgical route to the posterior mediobasal temporal lobe in the cadaveric studies. This approach provides an advantage over the subtemporal and transtemporal routes in that there is less temporal lobe retraction.
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Affiliation(s)
- Roham Moftakhar
- Department of Neurological Surgery, University of Wisconsin and Veterans Administration Hospital, Madison, Wisconsin
| | - Yusuf Izci
- Department of Neurological Surgery, University of Wisconsin and Veterans Administration Hospital, Madison, Wisconsin
| | - Mustafa K. Basşkaya
- Department of Neurological Surgery, University of Wisconsin and Veterans Administration Hospital, Madison, Wisconsin
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Schramm J, Aliashkevich AF. Surgery for temporal mediobasal tumors: experience based on a series of 235 patients. Neurosurgery 2007; 60:285-94; discussion 294-5. [PMID: 17290179 DOI: 10.1227/01.neu.0000249281.69384.d7] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To describe the clinical characteristics, diagnosis, various approaches, and outcomes in a retrospective review of a large series of temporomediobasal (TMB) tumors. METHODS Charts from 235 patients with TMB tumors were identified from the glioma and epilepsy surgery database and from the electronic operations log. Preoperative magnetic resonance imaging scans were available for all patients and postoperative follow-up was available for 155 of these patients (mean follow-up period, 59 mo; range, 2-172 mo). Preoperative symptoms, approaches, technical problems, and surgical complications are described. RESULTS Two hundred and thirty-five patients with intra-axial TMB tumors (mean age, 35 yr) were collected during an 11-year period. The largest tumor groups were astrocytomas (38.0%), gangliogliomas (29.8%), dysembryoplastic neuroepithelial tumor (11.1%), and glioblastomas (11.1%). The most frequent tumor location was the mesial Type A tumor (45.1%), with this type also showing the highest proportion of benign (World Health Organization Grades I and II) histological features (91.3%). Of all tumors, 76.2% were benign. Larger tumor size was associated with higher frequency of malignant histopathological findings. The leading symptom was epilepsy in 91% of patients, followed by drug-resistant epilepsy in 71.5%. Significant preoperative neurological deficits, such as hemiparesis or aphasia, were seen in 3.8% of the patients; another 12% had visual field deficits. Thirty-eight patients with low-grade tumors had undergone surgery previously. Several surgical approaches were chosen: transsylvian in 28%, anterior two-thirds temporal lobe resection in 23%, temporal pole resection in 15.3%, subtemporal in 19%, and transcortical in 6%. The most frequent neurological complications were transient: dysphasia (4.2%), hemiparesis (5%), and oculomotor disturbance (2.5%). Permanent nonvisual neurological complications occurred in fewer than 2% of the patients and significant new hemianopic defects were found in another 5.4% of the patients. The most severe complication was one intraoperative internal carotid artery lesion. One patient died. CONCLUSION Small tumor size, magnetic resonance imaging, and microsurgery have made resection of mostly benign TMB tumors possible in a large number of patients. This series supports the conclusion that these tumors can be operated on with a relative degree of safety for the patient, provided that the anatomy of the mesial temporal lobe and the variety of approaches are well known to the surgeon. However, because of the complex anatomic structures in the vicinity, transient neurological deterioration is not infrequent and certain neurological disturbances (e.g., quadrantanopia) even seem to be unavoidable, whereas permanent significant deficits are rare.
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Affiliation(s)
- Johannes Schramm
- Department of Neurosurgery, University of Bonn Medical Center, Bonn, Germany.
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Bassiouni H, Hunold A, Asgari S, Stolke D. Tentorial Meningiomas: Clinical Results in 81 Patients Treated Microsurgically. Neurosurgery 2004; 55:108-16; discussion 116-8. [PMID: 15214979 DOI: 10.1227/01.neu.0000126886.48372.49] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2003] [Accepted: 02/12/2004] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
Even during the microsurgical era, tentorial meningiomas present a formidable surgical challenge when tumor involves critical neurovascular structures. We report our experience with tentorial meningioma with regard to clinical presentation, diagnostic workup, microsurgical technique, complications, and follow-up results.
METHODS:
In a retrospective study, we reviewed the medical charts, neuroimaging data, and follow-up data of patients treated microsurgically for tentorial meningioma in our department between January 1989 and June 2002. Patients were routinely scheduled for clinical and radiological follow-up 6 months and 1 year after surgery. Thereafter, follow-up was performed every 1 or 2 years on the basis of the results of each follow-up examination.
RESULTS:
The main presenting symptoms of the patients (69 women and 12 men) were headache (75%), dizziness (49%), and gait disturbance (46%). The leading neurological signs were gait ataxia (52%) and cranial nerve deficits (28%). Extent of tumor resection was Simpson Grade I in 29 patients, Grade II in 45 patients, Grade III in 1 patient, Grade IV in 4 patients, and unknown in 2 patients. Permanent surgical morbidity and mortality were 19.8 and 2.5%, respectively. Clinical and magnetic resonance imaging follow-up was available in 74 patients for a period ranging from 1 to 13 years (mean, 5.9 yr). Of these, 64 patients (86%) have resumed normal life activity. Seven patients had tumor recurrence and four underwent reoperation.
CONCLUSION:
Careful preoperative planning of the surgical approach tailored to tumor location and extent is a prerequisite to achieve radical microsurgical tumor resection with minimal morbidity and mortality. Resection of an infiltrated but patent venous sinus is not recommended.
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Affiliation(s)
- Hischam Bassiouni
- Department of Neurosurgery, University Hospital Essen, Essen, Germany.
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Ulm AJ, Tanriover N, Kawashima M, Campero A, Bova FJ, Rhoton A. MICROSURGICAL APPROACHES TO THE PERIMESENCEPHALIC CISTERNS AND RELATED SEGMENTS OF THE POSTERIOR CEREBRAL ARTERY: COMPARISON USING A NOVEL APPLICATION OF IMAGE GUIDANCE. Neurosurgery 2004; 54:1313-27; discussion 1327-8. [PMID: 15157288 DOI: 10.1227/01.neu.0000126129.68707.e7] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2003] [Accepted: 02/12/2004] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To describe the exposure obtained through six approaches to the perimesencephalic cisterns with an emphasis on exposure of the posterior cerebral artery and its branches. METHODS Dissections in 12 hemispheres exposed the crural, ambient, and quadrigeminal cisterns and related segments of the posterior cerebral artery. A Stealth Image Guidance workstation (Medtronic Surgical Navigation Technologies, Louisville, CO) was used to compare the approaches. RESULTS The transsylvian approach exposed the interpeduncular and crural cisterns. The subtemporal approach exposed the interpeduncular and crural cisterns as well as the lower half of the ambient cistern. Temporal lobe retraction and the position of the vein of Labbé limited exposure of the quadrigeminal cistern. Occipital transtentorial and infratentorial supracerebellar approaches exposed the quadrigeminal and lower two-thirds of the ambient cistern. Transchoroidal approaches exposed the posterior third of the crural cistern, the upper two-thirds of the ambient cistern, and the proximal quadrigeminal cistern. Transchoroidal approaches exposed the posterior portion of the P2 segment (P2p) in 9 of 10 hemispheres and were the only approaches that exposed the lateral posterior choroidal arteries and the plexal segment of the anterior choroidal artery. Occipital transtentorial and infratentorial supracerebellar approaches provided access to the P3 segment in all cases and exposed the P2p segment in 4 of 10 hemispheres. The subtemporal approach provided access to the cisternal and crural segments of the anterior choroidal and medial posterior choroidal arteries and exposed the P2p segment in 3 of 10 hemispheres. CONCLUSION Surgical approaches to lesions of the perimesencephalic cisterns must be tailored to the site of the pathological findings. The most challenging area to expose is the upper half of the ambient cistern, particularly the P2p segment of the posterior cerebral artery.
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Affiliation(s)
- Arthur J Ulm
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, 32610, USA.
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Hostalot C, Carrasco A, Bilbao G, Pomposo I, Garibi YJM. [Tentorial meningiomas. Report of our series]. Neurocirugia (Astur) 2004; 15:119-27. [PMID: 15159789 DOI: 10.1016/s1130-1473(04)70490-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE The main objectives of this report are to describe the clinical and radiological features, surgical management, complications, and final outcome of patients with a tentorial meningioma. METHODS This is a retrospective study of 25 patients operated on for tentorial meningiomas at our department since december 1975 to may 2002. All the patients, except the first, were diagnosed by computed tomography; in 13 of them a magnetic resonance imaging was performed too; in 14 patients, diagnosis was completed with cerebral arteriography. The preoperative clinical condition, the interval between the first symptoms and the date of the operation, the postoperative morbidity and the recurrence are analysed. RESULTS There were 20 women and 5 men of ages ranging from 35 to 79 years (average of 54.6). Surgical removal was considered radical (Simpson I-II) in 22 patients. Of them one had a recurrence 25 years after the operation, another had three recurrences, in two years, that were reoperated, and a third one had recurrence at five years who did not require surgery. The postoperative mortality was 8%. The mean follow-up period was of 5.3 years. The final outcome was good recovery in 19 patients, moderate disability in 1 and death in 4. CONCLUSIONS Despite the advances in Neuroradiology and Microsurgery, these tumors represent a challenge for the neurosurgeon, due in some cases to a large tumor size and extension to critical areas. A removal as complete as possible allows minimizing the recurrence risk.
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Affiliation(s)
- C Hostalot
- Servicio de Neurocirugia del Hospital de Cruces (Bilbao), Barakaldo (Bizkaia)
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