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Kanjilal S, Bhaisora KS, Maurya VP, Halder A, Kumar A, Srivastava AK. Trans-temporal trans-choroidal resection of thalamic and thalamopeduncular tumors: how I do it. Acta Neurochir (Wien) 2024; 166:281. [PMID: 38967812 DOI: 10.1007/s00701-024-06175-y] [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] [Received: 11/28/2023] [Accepted: 06/23/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Surgical resection is the cornerstone of treatment for low-grade tumors, albeit total excision is beneficial. As the thalamus is surrounded by vital neurovascular system, lesions here present a surgical challenge. METHOD This article aims to demonstrate the trans-temporal, trans-choroidal fissure approach's effective surgical therapy on patients with thalamic lesions. With this approach, we were able to remove the tumor completely in three patients and almost completely in six more. Here we discuss a few technical details and potential hazards of the procedure with an operative video. CONCLUSION This approach provides excellent access to the deep areas of brain.
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Affiliation(s)
- Soumen Kanjilal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
| | - Kamlesh Singh Bhaisora
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India.
| | - Ved Prakash Maurya
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
| | - Abhishek Halder
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
| | - Ashutosh Kumar
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
| | - Arun Kumar Srivastava
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, UP, India
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Pan S, Koleske JP, Koller GM, Halupnik GL, Alli AHO, Koneru S, DeFreitas D, Ramagiri S, Strahle JM. Postnatal meningeal CSF transport is primarily mediated by the arachnoid and pia maters and is not altered after intraventricular hemorrhage-posthemorrhagic hydrocephalus. Fluids Barriers CNS 2024; 21:4. [PMID: 38191402 PMCID: PMC10773070 DOI: 10.1186/s12987-023-00503-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/12/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND CSF has long been accepted to circulate throughout the subarachnoid space, which lies between the arachnoid and pia maters of the meninges. How the CSF interacts with the cellular components of the developing postnatal meninges including the dura, arachnoid, and pia of both the meninges at the surface of the brain and the intracranial meninges, prior to its eventual efflux from the cranium and spine, is less understood. Here, we characterize small and large CSF solute distribution patterns along the intracranial and surface meninges in neonatal rodents and compare our findings to meningeal CSF solute distribution in a rodent model of intraventricular hemorrhage-posthemorrhagic hydrocephalus. We also examine CSF solute interactions with the tela choroidea and its pial invaginations into the choroid plexuses of the lateral, third, and fourth ventricles. METHODS 1.9-nm gold nanoparticles, 15-nm gold nanoparticles, or 3 kDa Red Dextran Tetramethylrhodamine constituted in aCSF were infused into the right lateral ventricle of P7 rats to track CSF circulation. 10 min post-1.9-nm gold nanoparticle and Red Dextran Tetramethylrhodamine injection and 4 h post-15-nm gold nanoparticle injection, animals were sacrificed and brains harvested for histologic analysis to identify CSF tracer localization in the cranial and spine meninges and choroid plexus. Spinal dura and leptomeninges (arachnoid and pia) wholemounts were also evaluated. RESULTS There was significantly less CSF tracer distribution in the dura compared to the arachnoid and pia maters in neonatal rodents. Both small and large CSF tracers were transported intracranially to the arachnoid and pia mater of the perimesencephalic cisterns and tela choroidea, but not the falx cerebri. CSF tracers followed a similar distribution pattern in the spinal meninges. In the choroid plexus, there was large CSF tracer distribution in the apical surface of epithelial cells, and small CSF tracer along the basolateral surface. There were no significant differences in tracer intensity in the intracranial meninges of control vs. intraventricular hemorrhage-posthemorrhagic hydrocephalus (PHH) rodents, indicating preserved meningeal transport in the setting of PHH. CONCLUSIONS Differential CSF tracer handling by the meninges suggests that there are distinct roles for CSF handling between the arachnoid-pia and dura maters in the developing brain. Similarly, differences in apical vs. luminal choroid plexus CSF handling may provide insight into particle-size dependent CSF transport at the CSF-choroid plexus border.
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Affiliation(s)
- Shelei Pan
- Department of Neurosurgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Joshua P Koleske
- Department of Neurosurgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Gretchen M Koller
- Department of Neurosurgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Grace L Halupnik
- Department of Neurosurgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Abdul-Haq O Alli
- Department of Neurosurgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Shriya Koneru
- Department of Neurosurgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Dakota DeFreitas
- Department of Neurosurgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Sruthi Ramagiri
- Department of Neurosurgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, 63110, USA
| | - Jennifer M Strahle
- Department of Neurosurgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, 63110, USA.
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Agosti E, De Maria L, Mattogno PP, Della Pepa GM, D’Onofrio GF, Fiorindi A, Lauretti L, Olivi A, Fontanella MM, Doglietto F. Quantitative Anatomical Studies in Neurosurgery: A Systematic and Critical Review of Research Methods. Life (Basel) 2023; 13:1822. [PMID: 37763226 PMCID: PMC10532642 DOI: 10.3390/life13091822] [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: 07/10/2023] [Revised: 08/17/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The anatomy laboratory can provide the ideal setting for the preclinical phase of neurosurgical research. Our purpose is to comprehensively and critically review the preclinical anatomical quantification methods used in cranial neurosurgery. METHODS A systematic review was conducted following the PRISMA guidelines. The PubMed, Ovid MEDLINE, and Ovid EMBASE databases were searched, yielding 1667 papers. A statistical analysis was performed using R. RESULTS The included studies were published from 1996 to 2023. The risk of bias assessment indicated high-quality studies. Target exposure was the most studied feature (81.7%), mainly with area quantification (64.9%). The surgical corridor was quantified in 60.9% of studies, more commonly with the quantification of the angle of view (60%). Neuronavigation-based methods benefit from quantifying the surgical pyramid features that define a cranial neurosurgical approach and allowing post-dissection data analyses. Direct measurements might diminish the error that is inherent to navigation methods and are useful to collect a small amount of data. CONCLUSION Quantifying neurosurgical approaches in the anatomy laboratory provides an objective assessment of the surgical corridor and target exposure. There is currently limited comparability among quantitative neurosurgical anatomy studies; sharing common research methods will provide comparable data that might also be investigated with artificial intelligence methods.
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Affiliation(s)
- Edoardo Agosti
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
| | - Lucio De Maria
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
- Division of Neurosurgery, Department of Clinical Neuroscience, Geneva University Hospitals (HUG), 1205 Geneva, Switzerland
| | - Pier Paolo Mattogno
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
| | - Giuseppe Maria Della Pepa
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
| | | | - Alessandro Fiorindi
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
| | - Liverana Lauretti
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
| | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili 1, 25121 Brescia, Italy; (E.A.); (A.F.); (M.M.F.)
| | - Francesco Doglietto
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy; (P.P.M.); (G.M.D.P.); (L.L.); (A.O.); (F.D.)
- Department of Neurosurgery, Università Cattolica del Sacro Cuore, 20123 Rome, Italy;
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Pan S, Koleske J, Koller GM, Halupnik GL, Alli AHO, Koneru S, DeFreitas D, Ramagiri U, Strahle JM. Meningeal CSF transport is primarily mediated by the arachnoid and pia maters during development. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.08.10.552826. [PMID: 37645776 PMCID: PMC10461931 DOI: 10.1101/2023.08.10.552826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Background The recent characterization of the glymphatic system and meningeal lymphatics has re-emphasized the role of the meninges in facilitating CSF transport and clearance. Here, we characterize small and large CSF solute distribution patterns along the intracranial and surface meninges in neonatal rodents and compare our findings to a rodent model of intraventricular hemorrhage-posthemorrhagic hydrocephalus. We also examine CSF interactions with the tela choroidea and its pial invaginations into the choroid plexuses of the lateral, third, and fourth ventricles. Methods 1.9-nm gold nanoparticles, 15-nm gold nanoparticles, or 3 kDa Red Dextran Tetramethylrhodamine constituted in aCSF were infused into the right lateral ventricle of P7 rats to track CSF circulation. 10 minutes post-1.9-nm gold nanoparticle and Red Dextran Tetramethylrhodamine injection and 4 hours post-15-nm gold nanoparticle injection, animals were sacrificed and brains harvested for histologic analysis to identify CSF tracer localization in the cranial and spine meninges and choroid plexus. Spinal dura and leptomeninges (arachnoid and pia) wholemounts were also performed. Results There was significantly less CSF tracer distribution in the dura compared to the arachnoid and pia maters in neonatal rodents. Both small and large CSF tracers were transported intracranially to the arachnoid and pia mater of the perimesencephalic cisterns and tela choroidea, but not the dura mater of the falx cerebri. CSF tracers followed a similar distribution pattern in the spinal meninges. In the choroid plexus, there was large CSF tracer distribution in the apical surface of epithelial cells, and small CSF tracer along the basolateral surface. There were no significant differences in tracer intensity in the intracranial meninges of control vs. intraventricular hemorrhage-posthemorrhagic hydrocephalus (PHH) rodents, indicating preserved meningeal transport in the setting of PHH. Conclusions Differential CSF tracer handling by the leptomeninges suggests that there are distinct roles for CSF handling between the arachnoid-pia and dura maters in the developing brain. Similarly, differences in apical vs. luminal choroid plexus CSF handling may provide insight into particle-size dependent CSF transport at the CSF-choroid plexus border.
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Serrato-Avila JL, Archila JAP, da Costa MDS, Biol PRR, Marques SR, de Moraes LOC, Yagmurlu K, Lawton MT, Cavalheiro S, Chaddad-Neto F. Microsurgical Anatomy of the Cerebellar Interpeduncular Entry Zones. World Neurosurg 2022; 166:e933-e948. [PMID: 35948221 DOI: 10.1016/j.wneu.2022.07.142] [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: 05/18/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The cerebellar interpeduncular region, particularly the middle cerebellar peduncle (MCP) and interpeduncular sulcus (IPS) are significant surgical relevance areas due to the high prevalence of vascular and tumoral pathologies, such as cavernomas, arteriovenous malformations, and gliomas. We defined safer access areas of the MCP and the IPS, according to the surface anatomy, involved vessels, and fiber tracts of the cerebellar interpeduncular region. METHODS Fifteen formalin-fixed and silicone-injected cadaveric heads and 23 human brainstems with attached cerebellums prepared with the Klingler's technique were bilaterally dissected to study the vascular and intrinsic anatomy. RESULTS Surface anatomy: The mean length of the IPS was 12.73 mm (standard deviation [SD],2.15 mm), and the average measured angle formed by the IPS and the lateral mesencephalic sulcus was 144.53°. The mean distance from the uppermost point of the IPS to cranial nerve IV was 2.63 mm (SD, 2.84 mm). Vascular anatomy: The perforating branches of the superior cerebellar peduncle, IPS, and MCP originated predominantly from the caudal trunk of the superior cerebellar artery. The inferior third of the superior cerebellar peduncle and IPS was the third most pierced by perforating arteries, and for the MCP, was its superior third. Crossing vessels: The branches of the pontotrigeminal vein and the caudal trunk of the superior cerebellar artery crossed the IPS mostly. The superior third of the IPS was the most crossed by arteries and veins. CONCLUSIONS The middle thirds of the IPS and MCP as entry zones might be safer than their superior and inferior thirds due to fewer perforating branches, arterial trunks, and veins crossing the sulcus as fewer eloquent tracts.
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Affiliation(s)
- Juan Leonardo Serrato-Avila
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, Sao Paulo, Brazil; Laboratory of Microneurosurgery Anatomy, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Juan Alberto Paz Archila
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, Sao Paulo, Brazil; Laboratory of Microneurosurgery Anatomy, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Marcos Devanir Silva da Costa
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, Sao Paulo, Brazil; Laboratory of Microneurosurgery Anatomy, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Paulo Ricardo Rocha Biol
- Laboratory of Microneurosurgery Anatomy, Universidade Federal de Sao Paulo, Sao Paulo, Brazil; Department of Morphology and Genetics, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Sergio Ricardo Marques
- Department of Morphology and Genetics, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | | | - Kaan Yagmurlu
- Departments of Neurosurgery and Neuroscience, University of Virginia, Health System, Charlottesville, Virginia, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Sergio Cavalheiro
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, Sao Paulo, Brazil; Laboratory of Microneurosurgery Anatomy, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Feres Chaddad-Neto
- Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, Sao Paulo, Brazil; Laboratory of Microneurosurgery Anatomy, Universidade Federal de Sao Paulo, Sao Paulo, Brazil; Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil.
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Serrato-Avila JL, Paz Archila JA, Costa MDSD, Rocha PR, Marques SR, Moraes LOCD, Cavalheiro S, Yağmurlu K, Lawton MT, Chaddad-Neto F. Microsurgical approaches to the cerebellar interpeduncular region: qualitative and quantitative analysis. J Neurosurg 2022; 136:1410-1423. [PMID: 34678772 DOI: 10.3171/2021.6.jns204457] [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: 12/29/2020] [Accepted: 06/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The cerebellar interpeduncular region (CIPR) is a gate for dorsolateral pontine and cerebellar lesions accessed through the supracerebellar infratentorial approach (SCITa), the occipital transtentorial approach (OTa), or the subtemporal transtentorial approach (STa). The authors sought to compare the exposures of the CIPR region that each of these approaches provided. METHODS Three approaches were performed bilaterally in eight silicone-injected cadaveric heads. The working area, area of exposure, depth of the surgical corridor, length of the interpeduncular sulcus (IPS) exposed, and bridging veins were statistically studied and compared based on each approach. RESULTS The OTa provided the largest working area (1421 mm2; p < 0.0001) and the longest surgical corridor (6.75 cm; p = 0.0006). Compared with the SCITa, the STa provided a larger exposure area (249.3 mm2; p = 0.0148) and exposed more of the length of the IPS (1.15 cm; p = 0.0484). The most bridging veins were encountered with the SCITa; however, no significant differences were found between this approach and the other approaches (p > 0.05). CONCLUSIONS To reach the CIPR, the STa provided a more extensive exposure area and more linear exposure than did the SCITa. The OTa offered a larger working area than the SCIT and the STa; however, the OTa had the most extensive surgical corridor. These data may help neurosurgeons select the most appropriate approach for lesions of the CIPR.
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Affiliation(s)
| | | | | | - Paulo Ricardo Rocha
- 2Laboratory of Microneurosurgery Anatomy, and
- 3Department of Morphology and Genetics, Universidade Federal de Sao Paulo, Brazil
| | | | | | - Sergio Cavalheiro
- 1Department of Neurology and Neurosurgery
- 2Laboratory of Microneurosurgery Anatomy, and
| | - Kaan Yağmurlu
- 4Departments of Neurosurgery and
- 5Neuroscience, University of Virginia Health System, Charlottesville, Virginia
| | - Michael T Lawton
- 6Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Feres Chaddad-Neto
- 1Department of Neurology and Neurosurgery
- 2Laboratory of Microneurosurgery Anatomy, and
- 7Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, Brazil
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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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Microsurgical anatomy and surgical exposure of the cerebellar peduncles. Neurosurg Rev 2022; 45:2095-2117. [PMID: 34997381 DOI: 10.1007/s10143-021-01701-3] [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: 07/18/2021] [Revised: 11/04/2021] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
Abstract
A better understanding of the surgical anatomy of the cerebellar peduncles in different surgical approaches and their relationship with other neural structures are delineated through cadaveric dissections. We aimed to revisit the surgical anatomy of the cerebellar peduncles to describe their courses along the brain stem and the cerebellum and revise their segmental classification in surgical areas exposed through different approaches. Stepwise fiber microdissection was performed along the cerebellar tentorial and suboccipital surfaces. Multiple surgical approaches in each of the cerebellar peduncles were compared in eight silicone-injected cadaveric whole heads to evaluate the peduncular exposure areas. From a neurosurgical point of view, the middle cerebellar peduncle (MCP) was divided into a proximal cisternal and a distal intracerebellar segments; the inferior cerebellar peduncle (ICP) into a ventricular segment followed by a posterior curve and a subsequent intracerebellar segment; the superior cerebellar peduncle (SCP) into an initial congregated, an intermediate intraventricular, and a distal intramesencephalic segment. Retrosigmoid and anterior petrosectomy approaches exposed the junction of the MCP segments; telovelar, supratonsillar, and lateral ICP approaches each reached different segments of ICP; paramedian supracerebellar infratentorial, suboccipital transtentorial, and combined posterior transpetrosal approaches displayed the predecussation SCP within the cerbellomesencephalic fissure, whereas the telovelar approach revealed the intraventricular SCP within the superolateral recess of the fourth ventricle. Better understanding of the microsurgical anatomy of the cerebellar peduncles in various surgical approaches and their exposure limits constitute the most critical aspect for the prevention of surgical morbidity during surgery in and around the pons and the upper medulla. Our findings help in evaluating radiological data and planning an operative procedure for cerebellar peduncles.
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Hou K, Lv X, Yu J. Endovascular Treatment of Posterior Cerebral Artery Trunk Aneurysm: The Status Quo and Dilemma. Front Neurol 2022; 12:746525. [PMID: 35069405 PMCID: PMC8778581 DOI: 10.3389/fneur.2021.746525] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 12/08/2021] [Indexed: 02/05/2023] Open
Abstract
The posterior cerebral artery (PCA) is an important artery that can be divided into four segments (P1-4): segments P1-2 are proximal segments, and segments P3-4 are distal segments. Various aneurysms can occur along the PCA trunk. True saccular aneurysms are rare, and most PCA trunk aneurysms are dissecting. Sometimes, the PCA trunk can give rise to flow-related aneurysms in association with high-flow arteriovenous shunt diseases or moyamoya disease and internal carotid artery occlusion. Some PCA trunk aneurysms require treatment, especially ruptured or large/giant aneurysms. Recently, endovascular treatment (EVT) has become the mainstream treatment for PCA trunk aneurysms, and it mainly involves reconstructive or deconstructive techniques. Traditional EVT includes selective coiling with/without stent or balloon assistance and parent artery occlusion (PAO). For proximal aneurysms, the PCA should be preserved. For distal aneurysms, PAO can be performed. However, during EVT, preservation of the PCA must naturally be the prime objective. Recently, flow-diverting stents have been used and are a revolutionary treatment for unruptured dissecting aneurysms of the PCA trunk. Despite the associated complications, EVT remains an effective method for treating PCA trunk aneurysms and can result in a good prognosis.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Xianli Lv
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jinlu Yu
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
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Egemen E, Celtikci P, Dogruel Y, Yakar F, Sahinoglu D, Farouk M, Adiguzel E, Ugur HC, Coskun E, Güngör A. Microsurgical and Tractographic Anatomical Study of Transtemporal-Transchoroidal Fissure Approaches to the Ambient Cistern. Oper Neurosurg (Hagerstown) 2021; 20:189-197. [PMID: 33313862 DOI: 10.1093/ons/opaa272] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/28/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Approaching ambient cistern lesions is still a challenge because of deep location and related white matter tracts (WMTs) and neural structures. OBJECTIVE To investigate the white matter anatomy in the course of 3 types of transtemporal-transchoroidal fissure approaches (TTcFA) to ambient cistern by using fiber dissection technique with translumination and magnetic resonance imaging fiber tractography. METHODS Eight formalin-fixed cerebral hemispheres were dissected on surgical corridor from the temporal cortex to the ambient cistern by using Klingler's method. The trans-middle temporal gyrus, trans-inferior temporal sulcus (TITS), and trans-inferior temporal gyrus (TITG) approaches were evaluated. WMTs that were identified during dissection were then reconstructed on the Human Connectome Project 1021 individual template for validation. RESULTS The trans-middle gyrus approach interrupted the U fibers, arcuate fasciculus (AF), the ventral segment of inferior frontoocipital fasciculus (IFOF), the temporal extensions of the anterior commissure (AC) posterior crura, the tapetum (Tp) fibers, and the anterior loop of the optic radiation (OR). The TITS approach interrupted U fibers, inferior longitudinal fasciculus (ILF), IFOF, and OR. The TITG approach interrupted the U fibers, ILF, and OR. The middle longitudinal fasciculus, ILF, and uncinate fasciculus (UF) were not interrupted in the trans-middle gyrus approach and the AF, UF, AC, and Tp fibers were not interrupted in the TITS/gyrus approaches. CONCLUSION Surgical planning of the ambient cistern lesions requires detailed knowledge about WMTs. Fiber dissection and tractography techniques improve the orientation during surgery and may help decrease surgical complications.
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Affiliation(s)
- Emrah Egemen
- Department of Neurosurgery, Pamukkale University School of Medicine, Denizli, Turkey
| | - Pinar Celtikci
- Department of Radiology, Baskent University, Ankara, Turkey
| | - Yücel Dogruel
- Department of Neurosurgery, Pamukkale University School of Medicine, Denizli, Turkey
| | - Fatih Yakar
- Department of Neurosurgery, Pamukkale University School of Medicine, Denizli, Turkey
| | - Defne Sahinoglu
- Department of Neurosurgery, Pamukkale University School of Medicine, Denizli, Turkey
| | - Mohamed Farouk
- Department of Neurosurgery, Mansoura University, Mansoura, Egypt
| | - Esat Adiguzel
- Department of Anatomy, Pamukkale University School of Medicine, Denizli, Turkey
| | - Hasan Caglar Ugur
- Department of Neurosurgery, Ankara University School of Medicine, Ibni Sina Hospital, Ankara, Turkey
| | - Erdal Coskun
- Department of Neurosurgery, Pamukkale University School of Medicine, Denizli, Turkey
| | - Abuzer Güngör
- Department of Neurosurgery, Neurosurgery Laboratory, Yeditepe University School of Medicine, Istanbul, Turkey
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11
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Hulou MM, Mirza FA. Commentary: Microsurgical and Tractographic Anatomical Study of Transtemporal-Transchoroidal Fissure Approaches to the Ambient Cistern. Oper Neurosurg (Hagerstown) 2021; 20:E249-E250. [PMID: 33377162 DOI: 10.1093/ons/opaa402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 10/10/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- M Maher Hulou
- Department of Neurosurgery, Kentucky Neuroscience Institute (KNI), University of Kentucky, Lexington, Kentucky
| | - Farhan A Mirza
- Department of Neurosurgery, Kentucky Neuroscience Institute (KNI), University of Kentucky, Lexington, Kentucky
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12
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How I do it: lateral supra-cerebellar infra-tentorial approach for P2-P3 junction cerebral aneurysms. Acta Neurochir (Wien) 2020; 162:2767-2772. [PMID: 32918194 DOI: 10.1007/s00701-020-04566-5] [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: 05/31/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND P2-P3 junction aneurysms are challenging to treat surgically because of their frequent complex morphology and their location deep in close proximity to the midbrain. The sub-temporal route requires significant retraction of the temporal lobe in addition to potential injury to the vein of Labbe. We describe the technique for treating such aneurysms via a lateral supra-cerebellar infra-tentorial (LSCIT) approach, which eliminates manipulation of the temporal lobe. METHOD Cadaveric dissection provided comprehensive understanding of relevant anatomy. Intraoperative video shows clipping of the aneurysm using a LSCIT approach. CONCLUSION LSCIT approach allows safe clipping of P2-P3 aneurysms with minimal brain manipulation.
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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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Silva AHD, Lo WB, Mundil NR, Walsh AR. Transtemporal approach to hypothalamic hamartomas in children: report of 3 cases. J Neurosurg Pediatr 2020; 25:588-596. [PMID: 32109874 DOI: 10.3171/2019.12.peds19231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 12/06/2019] [Indexed: 11/06/2022]
Abstract
The surgical approach to hypothalamic hamartomas (HHs) associated with medically refractory epilepsy is challenging because of these lesions' deep midline or paramedian location. Whether the aim is resection or disconnection, the surgical corridor dictates how complete a procedure can be achieved. Here, the authors report a transtemporal approach suitable for Delalande type I, inferior extraventricular component of type III, and type IV lesions. This approach provides optimal visualization of the plane between the hamartoma and the hypothalamus with no manipulation to the pituitary stalk and brainstem, allowing for extensive disconnection while minimizing injury to adjacent neurovascular structures.Through a 1-cm corticectomy in the middle temporal gyrus, a surgical tract is developed under neuronavigational guidance toward the plane of intended disconnection. On reaching the mesial temporal pia-arachnoid margin, it is opened, providing direct visualization of the hamartoma, which is then disconnected or resected as indicated. Critical neurovascular structures are generally not exposed through this approach and are preserved if encountered.Three patients (mean age 4.9 years) with intractable epilepsy were treated using this technique as part of the national Children's Epilepsy Surgery Service. Following resection, the patient in case 1 (Delalande type I) is seizure free off medication at 3 years' follow-up (Engel class IA). The patient in case 2 (Delalande type III) initially underwent partial disconnection through a transcallosal interforniceal approach and at first had significant seizure improvement before the seizures worsened in frequency and type. Complete disconnection of the residual lesion was achieved using the transtemporal approach, rendering this patient seizure free off medication at 14 months postsurgery (Engel class IA). The patient in case 3 (Delalande type IV) underwent incomplete disconnection with a substantial reduction in seizure frequency at 3 years' follow-up (Engel class IIIC). There were no surgical complications in any of the cases.The transtemporal approach is a safe and effective alternative to more conventional surgical approaches in managing HHs with intractable epilepsy.
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Xue G, Tang H, Liu P, Zuo Q, Yang P, Zhou Y, Li Q, Fang Y, Huang Q, Hong B, Xu Y, Zhao R, Liu J. Safety and Long-term Efficacy of Stent-assisted Coiling for the Treatment of Complex Posterior Cerebral Artery Aneurysms. Clin Neuroradiol 2019; 31:89-97. [PMID: 31418047 DOI: 10.1007/s00062-019-00825-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the safety and long-term efficacy of stent-assisted coiling for the treatment of complex posterior cerebral artery (PCA) aneurysms. METHODS Angiographic and clinical data of 23 patients harboring 23 complex PCA aneurysms treated with stent-assisted coiling from March 2010 to March 2017 were retrospectively reviewed. RESULTS In this study 8 (34.8%) aneurysms were located at the P1 segment, 7 (30.4%) at the junction of P1 and P2 segments (P1-2), and 8 (34.8%) at the P2 segment. The aneurysms were ruptured in 7 cases (30.4%). Thirteen were dissecting in nature, while the other 10 were classical saccular aneurysms. Of the patients, 5 (21.7%) had of history of recent head trauma, immediate angiographic results were Raymond class I in 5 (21.7%) cases, Raymond class II in 8 (34.8%), and Raymond class III in 10 (43.5%). Perioperative complications occurred in one case with occlusion of the PA due to acute in-stent thrombosis without any neurologic deficit at discharge. The last angiographic follow-up (mean 18.7 months) results demonstrated complete aneurysmal occlusion in 20 (87.0%) cases, PA occlusion in 1 (4.3%) and recurrence in 2 (8.7%). Of the two patients with aneurysm recurrence, one was treated by PA occlusion, and the other was treated with two overlapping stents. Clinical follow-up (mean 58.3 months) was available for all 23 patients, 22 (95.7%) patients had good neurologic outcomes (mRS score 0-2), and 1 (4.3%) patient died 7 months after the procedure for unknown reasons. CONCLUSION Stent-assisted coiling for the treatment of complex PCA aneurysms is safe and durable with a relatively low rate of complication and a relatively high rate of complete occlusion at long-term follow-up and is a promising alternative strategy for the reconstruction of the PCA.
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Affiliation(s)
- Gaici Xue
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, 200433, Shanghai, China
| | - Haishuang Tang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, 200433, Shanghai, China
| | - Peng Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, 200433, Shanghai, China
| | - Qiao Zuo
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, 200433, Shanghai, China
| | - Pengfei Yang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, 200433, Shanghai, China
| | - Yu Zhou
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, 200433, Shanghai, China
| | - Qiang Li
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, 200433, Shanghai, China
| | - Yibin Fang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, 200433, Shanghai, China
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, 200433, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, 200433, Shanghai, China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, 200433, Shanghai, China
| | - Rui Zhao
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, 200433, Shanghai, China.
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, 200433, Shanghai, China.
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Baran O, Baydin S, Gungor A, Balak N, Middlebrooks E, Saygi T, Aydin I, Tanriover N. Surgical Approaches to the Thalamus in Relation to the White Matter Tracts of the Cerebrum. World Neurosurg 2019; 128:e1048-e1086. [DOI: 10.1016/j.wneu.2019.05.068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 05/08/2019] [Indexed: 12/20/2022]
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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 2019; 130:1426-1434. [PMID: 29957111 DOI: 10.3171/2018.1.jns173139] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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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Lin BJ, Hong KT, Chung TT, Liu WH, Hueng DY, Chen YH, Ju DT, Ma HI, Liu MY, Hung HC, Tang CT. Endoscopic transorbital transtentorial approach to middle incisural space: preclinical cadaveric study. Acta Neurochir (Wien) 2019; 161:831-839. [PMID: 30758791 DOI: 10.1007/s00701-019-03831-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Endoscopic transorbital approach is a novel development of minimally invasive skull base surgery. Recently, anatomical studies have started to discuss the expanded utilization of endoscopic transorbital route for intracranial intradural lesions. The goal of this cadaveric study is to assess the feasibility of endoscopic transorbital transtentorial approach for exposure of middle incisural space. METHODS Anatomical dissections were performed in four human cadaveric heads (8 sides) using 0- and 30-degree endoscopes. A stepwise description of endoscopic transorbital transtentorial approach to middle incisural space and related anatomy was provided. RESULTS Orbital manipulation following superior eyelid crease incision with lateral canthotomy and cantholysis established space for bone drilling. Extradural stage consisted of extensive drilling of orbital roof of frontal bone, lessor, and greater wings of sphenoid bone. Intradural stage was composed of dissection of sphenoidal compartment of Sylvian fissure, lateral mobilization of mesial temporal lobe, and penetration of tentorium. A cross-shaped incision of tentorium provided direct visualization of crural cistern with anterolateral aspect of cerebral peduncle and upper pons. Interpeduncular cistern, prepontine cistern, and anterior portions of ambient and cerebellopontine cisterns were exposed by 30-degree endoscope. CONCLUSION The endoscopic transorbital transtentorial approach can be used as a minimally invasive surgery for exposure of middle incisural space. Extensive drilling of sphenoid wing and lateral mobilization of mesial temporal lobe are the main determinants of successful dissection. Further studies are needed to confirm the clinical feasibility of this novel approach.
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Grigoryan YA, Sitnikov AR, Grigoryan GY, Timoshenkov AV, Mishnyakova LP. [Surgical treatment of epilepsy in patients with mediobasal temporal cavernous malformations]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 82:45-56. [PMID: 30137038 DOI: 10.17116/neiro201882445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Epilepsy is a frequent clinical manifestation of cavernous malformations (CMs) of the mediobasal temporal region (MBTR). Surgical removal of CMs is an excellent technique for treating associated epilepsy and may range from pure lesionectomy to tailored resection of the temporal lobe. PURPOSE The study purpose was to determine the optimal surgical management for epilepsy in patients with CMs of the MBTR. MATERIAL AND METHODS We retrospectively analyzed the clinical data, neuroimaging findings, surgical techniques, and surgical outcomes in 11 patients with epilepsy and CMs of the MBTR. All patients underwent video-electroencephalography, magnetic resonance imaging, and computed tomography in the pre- and postoperative periods. Nine patients underwent preoperative implantation of foramen ovale electrodes. In all cases, surgery was accompanied by electrocorticography (ECoG). RESULTS CMs were located in the anterior MBTR in 7 cases, anterior and middle thirds of the MBTR in 1 case, middle third in 2 cases, and middle and posterior thirds in 1 case. In 8 patients, preoperative monitoring revealed a seizure onset area in the MBTR. These patients underwent cavernomectomy with ECoG-guided resection of the hemosiderin ring and adjacent tissue using the pterional (4 cases) or supracerebellar transtentorial approach (4). In 3 cases, anterior temporal lobectomy with cavernomectomy was additionally used due to spreading of pathological activity to the lateral temporal neocortex. Seizure control after surgery was excellent in 7 patients (class 1 ILAE) and good in 4 (class 2 ILAE). CONCLUSION Surgery in patients with epilepsy caused by CMs of the MBTR should be performed based on non-invasive and invasive presurgical evaluation. If the seizure onset area is located in the MBTR, lesionectomy with ECoG-guided resection of the adjacent temporal cortical areas can be performed using the pterional or supracerebellar transtentorial approach. Lateral spread of epileptic activity requires cavernomectomy and anterior temporal lobectomy.
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Affiliation(s)
| | - A R Sitnikov
- Treatment and rehabilitation center, Moscow, Russia
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Less is more: Parahippocampal resection or endoscopic assistance in ambient cistern surgery? Qualitative and quantitative assessment of subtemporal approach. J Clin Neurosci 2018; 53:203-208. [PMID: 29685409 DOI: 10.1016/j.jocn.2018.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/09/2018] [Indexed: 11/20/2022]
Abstract
The ambient cistern is an arachnoid complex that extends from the crural cistern to lateral border of cerebral colliculi. The subtemporal approach has been recognized as the best access to reach pathologies in the ambient cistern, however many disadvantages exist. The present work aims to analyze quantitatively the area of exposure provided by the subtemporal access. The objective is to evaluate if there are advantages of using the neuroendoscope in conventional subtemporal access when compared to the subtemporal access with resection of the parahippocampal gyrus. A subtemporal approach was performed in six brain hemispheres. Qualitative and quantitative analyses were made. The linear exposition of the vascular structures and the surgical exposure area were evaluated. The linear exposure to the posterior cerebral artery was 5.95 for subtemporal access (ST) and 13.6 for subtemporal access with resection of the parahippocampal gyrus (STh) (p = 0.019). The total exposure area was 104.8 mm2 for ST and 210.5 for STh (p = 0.0001). Regarding endoscope assistance the medial area, ST was 81.0 mm2, and STend was 176.2 mm2 (p = 0.038). For the total area of exposure, we obtained a value of 210.5 mm2 for ST and a value of 391.3 mm2 for STend (p = 0.041). In conventional subtemporal access, the use of the neuroendoscopes avoids the need for resection of the parahippocampal gyrus for better visualization of the ambient cistern structures.
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de Notaris M, Laleva L, Spiriev T, Dallan I, Di Nuzzo G, Pineda J, Prats-Galino A, Catapano G. Frontolateral Approach Combined with Endoscopic Endonasal Extradural Posterior Clinoidectomy to the Upper Clival Region: Anatomic and Feasibility Study. World Neurosurg 2017; 111:86-93. [PMID: 29269065 DOI: 10.1016/j.wneu.2017.12.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/04/2017] [Accepted: 12/08/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Surgical management of lesions located in the upper clival region is challenging. Complex open transcranial approaches have been used to reach surgical targets in these areas. The frontotemporozygomatic approach combined with an intradural posterior clinoidectomy has been proposed as the most reliable route to manage such lesions. We investigated combining a minimally invasive endoscopic endonasal extradural posterior clinoidectomy (EPC) with a standard frontolateral approach to expand the working area within the upper clival region. METHODS Investigators dissected 10 human cadaveric heads at the Laboratory of Surgical NeuroAnatomy of the University of Barcelona. The heads were positioned to simulate a supine position, enabling the simultaneous use of both endonasal and frontolateral routes. The dissections were divided into 3 steps-standard frontolateral approach, EPC, and re-evaluation of the frontolateral route-aiming to compare the surgical exposure before and after EPC. RESULTS After EPC, through the frontolateral pathway it was possible to improve visualization and working angles to the interpeduncular fossa and retrosellar and upper clival regions. Increase in extension of the carotid-oculomotor window was 7 mm and 10 mm before and after the posterior clinoidectomy, respectively. CONCLUSIONS EPC provided extra working space for the frontolateral approach to the upper clival area with 42.8% expansion of the carotid-oculomotor triangle. Surgical series are needed to demonstrate clinical advantages and disadvantages of this novel combined approach.
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Affiliation(s)
- Matteo de Notaris
- Department of Neuroscience, "G. Rummo" Hospital, Neurosurgery Operative Unit, Benevento, Italy.
| | - Lili Laleva
- Unit of Otorhinolaryngology, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Toma Spiriev
- Unit of Otorhinolaryngology, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Iacopo Dallan
- Department of Neurosurgery, Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Giuseppe Di Nuzzo
- Department of Neuroscience, "G. Rummo" Hospital, Neurosurgery Operative Unit, Benevento, Italy
| | - Jose Pineda
- Laboratory of Surgical NeuroAnatomy, Human Anatomy and Embryology Unit, University of Barcelona Faculty of Medicine, Barcelona, Spain
| | - Alberto Prats-Galino
- Laboratory of Surgical NeuroAnatomy, Human Anatomy and Embryology Unit, University of Barcelona Faculty of Medicine, Barcelona, Spain
| | - Giuseppe Catapano
- Department of Neuroscience, "G. Rummo" Hospital, Neurosurgery Operative Unit, Benevento, Italy
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Endoscope-Assisted Microsurgical Subtemporal Keyhole Approach to the Posterolateral Suprasellar Region and Basal Cisterns. World Neurosurg 2017; 103:114-121. [DOI: 10.1016/j.wneu.2017.02.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/08/2017] [Accepted: 02/09/2017] [Indexed: 11/20/2022]
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Grigoryan YA, Sitnikov AR, Timoshenkov AV, Grigoryan GY. [An aneurysm of the medial posterior choroidal artery: a case report and a literature review]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2017; 81:101-107. [PMID: 28914876 DOI: 10.17116/neiro2017814101-107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Aneurysms of the medial posterior choroidal artery are very rare. To date, only 5 cases have been reported. The article presents a case of successful surgical treatment of an aneurysm of the medial posterior choroidal artery and a literature review. CLINICAL CASE A 57-year-old male was admitted to the Center 1 month after a massive subarachnoid hemorrhage. CT angiography revealed an aneurysm of the right posterior medial choroidal artery in the perimesencephalic cistern and resolved hemorrhage. TREATMENT The paramedian supracerebellar transtentorial approach to the lateral surface of the midbrain was used. The posterior cerebral artery was identified in the perimesencephalic cistern, and the medial posterior choroidal artery aneurysm was isolated and successfully clipped, with the parent artery being preserved. Postoperative CT and MRI scans revealed a small asymptomatic ischemic lesion in the tectal region on the right. The patient was discharged without any neurological symptoms 10 days after surgery. CONCLUSION Medial posterior choroidal artery aneurysms can be clipped using the paramedian supracerebellar transtentorial approach.
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Ajler P, Bravo MC, Garategui L, Goldschmidt E, Isolan G, Campero Á. [Microsurgical approach to the ambient cistern]. Surg Neurol Int 2016; 7:S861-S867. [PMID: 27999709 PMCID: PMC5154204 DOI: 10.4103/2152-7806.194493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 08/31/2016] [Indexed: 12/02/2022] Open
Abstract
Objetivo: Describir paso a paso el abordaje a la cisterna ambiens por la vía suboccipital retrosigmoidea supracerebelosa infratentorial (SRSI). Descripción: El abordaje SRSI se realiza de la misma manera que el abordaje suboccipital retrosigmoideo (SR), utilizado habitualmente para acceder a la patología del ángulo pontocerebeloso, con las siguientes modificaciones: (1) utilizamos siempre la posición semisentado, (2) la craneotomia-craniectomia debe exponer el seno transverso y extenderse 5 cm medialmente hacia el inion, (3) al realizar la apertura dural es necesario rebatir la duramadre junto con el seno transverso hacia cefálico con puntos de tracción, (4) bajo magnificación con microscopio quirúrgico se debe realizar la apertura de la cisterna cerebelobulbar para drenar líquido cefalorraquídeo, (5) en el plano supracerebeloso es fundamental cortar las bridas aracnoidales y de ser necesario debemos coagular y cortar las venas puente, todas estas maniobras sumadas al efecto de la gravedad brindan mayor apertura del corredor supracerebeloso. Conclusión: El abordaje a la cisterna ambiens por la vía SRSI es una opción segura para el acceso de patologías tumorales que se alojan en esta zona con un componente predominantemente infratentorial.
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Affiliation(s)
- Pablo Ajler
- Servicio de Neurocirugía, Hospital Italiano de Buenos Aires, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Michael Cruz Bravo
- Servicio de Neurocirugía, Hospital Italiano de Buenos Aires, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Lucas Garategui
- Servicio de Neurocirugía, Hospital Italiano de Buenos Aires, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ezequiel Goldschmidt
- Servicio de Neurocirugía, Hospital Italiano de Buenos Aires, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Gustavo Isolan
- Centro Avançado de Neurologia e Neurocirurgia (CEANNE), Graduate Course in surgery, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brasil
| | - Álvaro Campero
- Servicio de Neurocirugía, Hospital Padilla, Tucumán, Argentina
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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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Figueiredo EG, Beer-Furlan A, Welling LC, Ribas EC, Schafranski M, Crawford N, Teixeira MJ, Rhoton AL, Spetzler RF, Preul MC. Microsurgical Approaches to the Ambient Cistern Region: An Anatomic and Qualitative Study. World Neurosurg 2016; 87:584-90. [DOI: 10.1016/j.wneu.2015.10.063] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 10/11/2015] [Accepted: 10/12/2015] [Indexed: 11/25/2022]
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Quantification and comparison of neurosurgical approaches in the preclinical setting: literature review. Neurosurg Rev 2016; 39:357-68. [PMID: 26782812 DOI: 10.1007/s10143-015-0694-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 03/25/2015] [Accepted: 06/27/2015] [Indexed: 12/14/2022]
Abstract
There is a growing awareness of the need for evidence-based surgery and of the issues that are specific to research in surgery. Well-conducted anatomical studies can represent the first, preclinical step for evidence-based surgical innovation and evaluation. In the last two decades, various reports have quantified and compared neurosurgical approaches in the anatomy laboratory using different methods and technology. The aim of this study was to critically review these papers. A PubMed and Scopus search was performed to select articles that quantified and compared different neurosurgical approaches in the preclinical setting. The basic characteristics that anatomically define a surgical approach were defined. Each study was analyzed for measured features and quantification method and technique. Ninety-nine papers, published from 1990 to 2013, were included in this review. A heterogeneous use of terms to define the features of a surgical approach was evident. Different methods to study these features have been reported; they are generally based on quantification of distances, angles, and areas. Measuring tools have evolved from the simple ruler to frameless stereotactic devices. The reported methods have each specific advantages and limits; a common limitation is the lack of 3D visualization and surgical volume quantification. There is a need for a uniform nomenclature in anatomical studies. Frameless stereotactic devices provide a powerful tool for anatomical studies. Volume quantification and 3D visualization of the surgical approach is not provided with most available methods.
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Figueiredo EG, Beer-Furlan A, Nakaji P, Crawford N, Welling LC, Ribas EC, Teixeira MJ, Rhoton AL, Spetzler RF, Preul MC. The Role of Endoscopic Assistance in Ambient Cistern Surgery: Analysis of Four Surgical Approaches. World Neurosurg 2015; 84:1907-15. [DOI: 10.1016/j.wneu.2015.08.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 08/24/2015] [Accepted: 08/25/2015] [Indexed: 11/26/2022]
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Komune N, Yagmurlu K, Matsuo S, Miki K, Abe H, Rhoton AL. Auditory brainstem implantation: anatomy and approaches. Neurosurgery 2015; 11 Suppl 2:306-20; discussion 320-1. [PMID: 25793729 DOI: 10.1227/neu.0000000000000736] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Auditory brainstem implantation at the cochlear nuclei used mainly for neurofibromatosis type 2 patients with bilateral loss of the cochlear nerves has more recently been extended to the inferior colliculus. OBJECTIVE To examine the microsurgical and endoscopic anatomy of the cochlear nuclei and inferior colliculus as seen through the translabyrinthine and retrosigmoid approaches used for cochlear nuclei and inferior collicular implantation. METHODS Ten cerebellopontine angles of formalin-fixed adult cadaveric heads were examined with the aid of the surgical microscope and endoscope. The ascending auditory pathways between the cochlear nuclei and inferior colliculi and above were examined by the fiber dissection technique. RESULTS Both the translabyrinthine and retrosigmoid routes provide sufficient exposure for concurrent tumor removal and implantation at either the cochlear nuclei or inferior colliculus. The position of the inferior colliculus in the auditory pathways and its accessibility in the infratentorial supracerebellar exposure directed through either the translabyrinthine or retrosigmoid approach makes it an alternative site for electrode placement if the cochlear nuclei are not functionally or structurally suitable for implantation. Endoscopic assistance may aid the exposure and electrode placement at either site. CONCLUSION The translabyrinthine or retrosigmoid approaches provide access to the cochlear nuclei for implantation and also to the inferior colliculus through the translabyrinthine or retrosigmoid infratentorial supracerebellar route. The endoscope may aid in exposing either site.
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Affiliation(s)
- Noritaka Komune
- *Department of Neurosurgery, University of Florida, College of Medicine, Gainesville, Florida; ‡Department of Neurosurgery, Fukuoka University, Fukuoka, Japan
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Wong RH, De Los Reyes K, Alikhani P, Sivakanthan S, van Gompel J, van Loveren H, Agazzi S. The Subtemporal Approach to Retroinfundibular Craniopharyngiomas: A New Look at an Old Approach. Oper Neurosurg (Hagerstown) 2015; 11:495-503. [PMID: 29506162 DOI: 10.1227/neu.0000000000000972] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 06/22/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Retrochiasmatic, retroinfundibular craniopharyngiomas are surgically challenging tumors. Anterolateral, posterolateral, and endoscopic endonasal approaches represent the most commonly used techniques to access these tumors, but all require an extensive exposure time, and each has its own risks and limitations. The subtemporal approach is a well-known neurosurgical approach that is rarely described for craniopharyngiomas. OBJECTIVE To assess the feasibility, advantages, and disadvantages of a subtemporal approach for craniopharyngiomas. METHODS Five patients with retrochiasmatic craniopharyngiomas where the majority of the tumor extended behind the dorsal clival line underwent a subtemporal approach for resection. Extent of resection, degree of temporal lobe injury, visual and endocrine outcomes, and time to recurrence were analyzed. RESULTS Average tumor volume was 6.4 cm3. Near-total resection was achieved in 80% (4/5) and subtotal in 20% (1/5). All patients had stable or improved vision. There was 1 new permanent endocrine deficiency. Minimal temporal lobe edema was observed in 80% (4/5) of patients. Three patients required postoperative radiation. CONCLUSION The subtemporal approach represents a feasible approach for retrochiasmatic, retroinfundibular craniopharyngiomas when gross total resection is not mandatory. It provides rapid access to the tumor and a caudal-to-cranial visualization that promotes minimal manipulation of critical neurovascular structures, particularly the optic apparatus.
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Affiliation(s)
- Ricky H Wong
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Kenneth De Los Reyes
- Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, California
| | - Puya Alikhani
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Sananthan Sivakanthan
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | | | - Harry van Loveren
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida
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Oyama K, Prevedello DM, Ditzel Filho LFS, Muto J, Gun R, Kerr EE, Otto BA, Carrau RL. Anatomic comparison of the endonasal and transpetrosal approaches for interpeduncular fossa access. Neurosurg Focus 2015; 37:E12. [PMID: 25270131 DOI: 10.3171/2014.7.focus14329] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The interpeduncular cistern, including the retrochiasmatic area, is one of the most challenging regions to approach surgically. Various conventional approaches to this region have been described; however, only the endoscopic endonasal approach via the dorsum sellae and the transpetrosal approach provide ideal exposure with a caudal-cranial view. The authors compared these 2 approaches to clarify their limitations and intrinsic advantages for access to the interpeduncular cistern. METHODS Four fresh cadaver heads were studied. An endoscopic endonasal approach via the dorsum sellae with pituitary transposition was performed to expose the interpeduncular cistern. A transpetrosal approach was performed bilaterally, combining a retrolabyrinthine presigmoid and a subtemporal transtentorium approach. Water balloons were used to simulate space-occupying lesions. "Water balloon tumors" (WBTs), inflated to 2 different volumes (0.5 and 1.0 ml), were placed in the interpeduncular cistern to compare visualization using the 2 approaches. The distances between cranial nerve (CN) III and the posterior communicating artery (PCoA) and between CN III and the edge of the tentorium were measured through a transpetrosal approach to determine the width of surgical corridors using 0- to 6-ml WBTs in the interpeduncular cistern (n = 8). RESULTS Both approaches provided adequate exposure of the interpeduncular cistern. The endoscopic endonasal approach yielded a good visualization of both CN III and the PCoA when a WBT was in the interpeduncular cistern. Visualization of the contralateral anatomical structures was impaired in the transpetrosal approach. The surgical corridor to the interpeduncular cistern via the transpetrosal approach was narrow when the WBT volume was small, but its width increased as the WBT volume increased. There was a statistically significant increase in the maximum distance between CN III and the PCoA (p = 0.047) and between CN III and the tentorium (p = 0.029) when the WBT volume was 6 ml. CONCLUSIONS Both approaches are valid surgical options for retrochiasmatic lesions such as craniopharyngiomas. The endoscopic endonasal approach via the dorsum sellae provides a direct and wide exposure of the interpeduncular cistern with negligible neurovascular manipulation. The transpetrosal approach also allows direct access to the interpeduncular cistern without pituitary manipulation; however, the surgical corridor is narrow due to the surrounding neurovascular structures and affords poor contralateral visibility. Conversely, in the presence of large or giant tumors in the interpeduncular cistern, which widen the spaces between neurovascular structures, the transpetrosal approach becomes a superior route, whereas the endoscopic endonasal approach may provide limited freedom of movement in the lateral extension.
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Affiliation(s)
- Kenichi Oyama
- Department of Neurological Surgery, The Ohio State University, Wexner Medical Center, Columbus, Ohio
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Takeuchi S, Tanikawa R, Tsuboi T, Noda K, Oda J, Miyata S, Ota N, Yoshikane T, Kamiyama H. Superficial temporal artery to proximal posterior cerebral artery bypass through the anterior temporal approach. Surg Neurol Int 2015; 6:95. [PMID: 26097774 PMCID: PMC4455125 DOI: 10.4103/2152-7806.157949] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/13/2014] [Indexed: 11/24/2022] Open
Abstract
Background: The superficial temporal artery (STA) to proximal posterior cerebral artery (PCA) (P2 segment) bypass is one of the most difficult procedures to perform because the proximal PCA is located deep and high within the ambient cistern. STA to proximal PCA bypass is usually performed through a subtemporal approach or posterior transpetrosal approach, and rarely through a transsylvian approach. The aim of this study was to describe the operative technique of STA to proximal PCA bypass through a modified transsylvian approach (anterior temporal approach). Methods: STA to proximal PCA bypass was performed through an anterior temporal approach in three patients with intracranial aneurysm. We describe the details of the surgical technique. Results: The STA was successfully anastomosed to the proximal PCA in all cases. One patient suffered hemiparesis and aphasia due to infarction in the anterior thalamoperforating artery territory. Conclusions: STA to proximal PCA bypass can be performed through an anterior temporal approach in selected patients. We recommend that every precaution, including complete hemostasis, placement of cellulose sponges beneath the recipient artery to elevate the site of the anastomosis, and placement of a continuous drainage tube at the bottom of the operative field to avoid blood contamination during the anastomosis, should be taken to shorten the temporary occlusion time.
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Affiliation(s)
- Satoru Takeuchi
- Department of Neurosurgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Rokuya Tanikawa
- Department of Neurosurgery, Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Toshiyuki Tsuboi
- Department of Neurosurgery, Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Kosumo Noda
- Department of Neurosurgery, Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Junpei Oda
- Department of Neurosurgery, Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Shiro Miyata
- Department of Neurosurgery, Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Nakao Ota
- Department of Neurosurgery, Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Tsutomu Yoshikane
- Department of Neurosurgery, Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Hiroyasu Kamiyama
- Department of Neurosurgery, Teishinkai Hospital, Sapporo, Hokkaido, Japan
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Serrone JC, Maekawa H, Tjahjadi M, Hernesniemi J. Aneurysmal subarachnoid hemorrhage: pathobiology, current treatment and future directions. Expert Rev Neurother 2015; 15:367-80. [PMID: 25719927 DOI: 10.1586/14737175.2015.1018892] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Aneurysmal subarachnoid hemorrhage is the most devastating form of stroke. Many pathological mechanisms ensue after cerebral aneurysm rupture, including hydrocephalus, apoptosis of endothelial cells and neurons, cerebral edema, loss of blood-brain barrier, abnormal cerebral autoregulation, microthrombosis, cortical spreading depolarization and macrovascular vasospasm. Although studied extensively through experimental and clinical trials, current treatment guidelines to prevent delayed cerebral ischemia is limited to oral nimodipine, maintenance of euvolemia, induction of hypertension if ischemic signs occur and endovascular therapy for patients with continued ischemia after induced hypertension. Future investigations will involve agents targeting vasodilation, anticoagulation, inhibition of apoptosis pathways, free radical neutralization, suppression of cortical spreading depolarization and attenuation of inflammation.
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Affiliation(s)
- Joseph C Serrone
- Department of Neurosurgery, Töölö Hospital, University of Helsinki, Topeliuksenkatu 5, PO Box 266, 00029 HUS, Helsinki, Finland
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Tanriover N, Kucukyuruk B, Ulu MO, Isler C, Sam B, Abuzayed B, Uzan M, Ak H, Tuzgen S. Microsurgical anatomy of the cisternal anterior choroidal artery with special emphasis on the preoptic and postoptic subdivisions. J Neurosurg 2014; 120:1217-28. [DOI: 10.3171/2014.1.jns131325] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The object of this study was to delineate the microsurgical anatomy of the cisternal segment of the anterior choroidal artery (AChA). The authors also propose a new classification of this segment on the basis of its complicated course within the carotid and crural cisterns in relation to important neurovascular structures, and the site of origin, course, and areas of supply of perforating arteries.
Methods
Thirty cadaveric cerebral hemispheres injected with colored latex were dissected under surgical magnification to view the cisternal segment of the AChA and its perforators. Fiber dissections using the Klingler technique were performed in two additional latex injected hemispheres to follow the penetration points, courses, and terminal areas of supply of perforating branches that arise from the cisternal segment of the AChA.
Results
The cisternal segment of the AChA was divided into pre- and postoptic parts that meet at the artery's genu, the most medial extension point of the cisternal segment where the artery makes an abrupt turn after passing under the optic tract. The preoptic part of the AChA extended from its origin at the inferomedial side of the internal carotid artery to the artery's genu, which is commonly located just inferomedial to the initial part of the optic tract. The postoptic part coursed within the crural cistern and extended from the genu to the inferior choroidal point. The genu of the AChA was 8 mm medial to the artery's origin and was located medial to the optic tract in 13% of the hemispheres. The postoptic part was longer than the preoptic part in all hemispheres and had more perforating arteries supplying critical deep structures (preoptic 3.4 per hemisphere vs postoptic 4.6 per hemisphere), and these results were statistically significant (p = 0.01). At the preoptic part, perforating arteries arose from the superolateral portion of the artery and coursed laterally; at the postoptic part, perforators arose from the inferomedial portion of the artery and coursed medially. Perforating arteries from both segments passed most commonly to the optic tract, followed by the anterior segment and apex of uncus in the preoptic part and the cerebral peduncle in the postoptic part.
Conclusions
Both parts of the cisternal segment of the AChA come into surgical view during surgeries for different pathologies in and around the perimesencephalic cisterns. However, attending to the artery's genu and defining pre- and postoptic parts during surgery may help the surgeon locate the origin and eventual course of these perforators, and even estimate the terminal areas of supply of most of the perforating arteries. The proposed classification system can prove helpful in planning any operative procedure along the crural cistern and may reduce the probability of inadvertent injury to perforating branches of the cisternal segment.
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Affiliation(s)
- Necmettin Tanriover
- 1Department of Neurosurgery, Cerrahpaşa Medical Faculty, Istanbul University
| | - Baris Kucukyuruk
- 1Department of Neurosurgery, Cerrahpaşa Medical Faculty, Istanbul University
| | - Mustafa Onur Ulu
- 1Department of Neurosurgery, Cerrahpaşa Medical Faculty, Istanbul University
| | - Cihan Isler
- 1Department of Neurosurgery, Cerrahpaşa Medical Faculty, Istanbul University
| | - Bulent Sam
- 2Istanbul Headquarters of the Forensic Medicine Institute, Ministry of Justice; and
| | - Bashar Abuzayed
- 1Department of Neurosurgery, Cerrahpaşa Medical Faculty, Istanbul University
| | - Mustafa Uzan
- 1Department of Neurosurgery, Cerrahpaşa Medical Faculty, Istanbul University
| | - Halil Ak
- 1Department of Neurosurgery, Cerrahpaşa Medical Faculty, Istanbul University
| | - Saffet Tuzgen
- 3Department of Neurosurgery, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
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Doglietto F, Maira G. Transsphenoidal Surgery for Lesions Involving the Interpeduncular Fossa: What If the Path Is Not Created By the Tumor? World Neurosurg 2014; 81:275-8. [DOI: 10.1016/j.wneu.2013.01.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 01/12/2013] [Indexed: 10/27/2022]
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Straus D, Byrne RW, Sani S, Serici A, Moftakhar R. Microsurgical anatomy of the transsylvian translimen insula approach to the mediobasal temporal lobe: Technical considerations and case illustration. Surg Neurol Int 2014; 4:159. [PMID: 24404402 PMCID: PMC3883274 DOI: 10.4103/2152-7806.123285] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 10/18/2013] [Indexed: 11/28/2022] Open
Abstract
Background: Various vascular, neoplastic, and epileptogenic pathologies occur in the mediobasal temporal region. A transsylvian translimen insula (TTI) approach can be used as an alternative to temporal transcortical approach to the mediobasal temporal region. The aim of this study was to demonstrate the surgical anatomy of the TTI approach, including the gyral, sulcal, and vascular anatomy in and around the limen insula. The use of this approach is illustrated in the resection of a complex arteriovenous malformation. Methods: The TTI approach to the mediobasal temporal region was performed on three silicone-injected cadaveric heads. The gyral, sulcal, and arterial anatomy of the limen insula was studied in six formalin-fixed injected hemispheres. Results: The TTI approach provided access to the anterior and middle segments of the mediobasal temporal lobe region as well as allowing access to temporal horn of the lateral ventricle. Using this approach we were able to successfully resect an arteriovenous malformation of the dominant medial temporal lobe. Conclusion: The TTI approach provides a viable surgical route to the region of mediobasal temporal lobe region. This approach offers an advantage over the temporal transcortical route in that there is less risk of damage to optic radiations and speech area in the dominant hemisphere.
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Affiliation(s)
- David Straus
- Department of Neurological Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Richard W Byrne
- Department of Neurological Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Sepehr Sani
- Department of Neurological Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Anthony Serici
- Department of Neurological Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Roham Moftakhar
- Department of Neurological Surgery, Rush University Medical Center, Chicago, IL, USA
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Krähenbühl AK, Baldauf J, Gaab MR, Schroeder HWS. Endoscopic temporal ventriculocisternostomy: an option for the treatment of trapped temporal horns. J Neurosurg Pediatr 2013; 11:568-74. [PMID: 23521153 DOI: 10.3171/2013.2.peds12417] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Entrapment of the temporal horn is a rare form of isolated hydrocephalus. Standard treatment has not yet been established for this condition, and only a few cases have been reported in the literature. The authors reviewed their prospectively maintained database to report their experience with endoscopic temporal ventriculocisternostomy. All endoscopic operations performed in the Department of Neurosurgery at Ernst Moritz Arndt University between March 1993 and August 2012 were reviewed, and a retrospective chart review of all patients with temporal ventriculocisternostomy was performed. Four patients were identified (3 children and 1 adult). In 3 patients, the condition developed after tumor resection, and in 1 patient it developed due to postmeningitic multiloculated hydrocephalus. In 2 patients, a recurrent trapped temporal horn developed. Refenestration was successful in one of these patients, and dilation in the trigone area with a subsequent stomy of the septum pellucidum was successful in the other. In 1 patient, postoperative meningitis developed, which was treated with antibiotics. Endoscopic temporal ventriculocisternostomy is an option in the treatment of trapped temporal horns. However, more experience is required to recommend it as the treatment of choice.
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Affiliation(s)
- Anna K Krähenbühl
- Department of Neurosurgery, Ernst Moritz Arndt University, Greifswald, Germany.
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Salma A, Alkandari A, Sammet S, Ammirati M. A new methodology for laboratory evaluation of neurosurgical approaches based on the volume and shape of the surgical space with a mathematical model to quantify the surgical maneuverability in laboratory settings. J Neurol Surg B Skull Base 2013; 73:64-70. [PMID: 23372997 DOI: 10.1055/s-0032-1304558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 08/10/2011] [Indexed: 10/28/2022] Open
Abstract
We conducted this study to validate the volume/shape of the surgical exposure and to introduce a mathematical model to quantify the maneuverability in a surgical space. We executed the pterional and lateral supraorbital approach four times in fresh cadavers in skull base laboratory. The surgical volumes were filled with a computed tomography (CT)-imageable mixture; CT scans were obtained to evaluate the volume and shape of the surgical space. The volume of the surgical space was 23.60 and 32.90 mL for the lateral supraorbital and pterional approach, respectively, (p < 0.05). The three-dimensional shape of the lateral supraorbital approach was cylindrical and that of the pterional approach pyramidal. The volume of the surgical approach can be used to define, together with other variables, the maneuverability (maneuvering in a surgical volume) by using the following formula [Formula: see text] where M, A, V, and L represent the maneuverability, the degree of the surgical freedom, the volume of the surgical exposure, and the surgical depth, respectively. Volume and shape of the surgical exposure are two objective parameters that can be used to define and contrast different microsurgical approaches in a laboratory setting. The volume of the surgical exposure may be integrated into a mathematical formula defining maneuverability.
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Hatano T, Bozinov O, Burkhardt JK, Bertalanffy H. Surgical treatment of tentorial dural arteriovenous fistulae located around the tentorial incisura. Neurosurg Rev 2013; 36:429-35. [DOI: 10.1007/s10143-013-0448-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 08/10/2012] [Accepted: 10/06/2012] [Indexed: 11/28/2022]
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Silva D, Attia M, Kandasamy J, Alimi M, Anand VK, Schwartz TH. Endoscopic endonasal transsphenoidal "above and below" approach to the retroinfundibular area and interpeduncular cistern--cadaveric study and case illustrations. World Neurosurg 2012; 81:374-84. [PMID: 23022634 DOI: 10.1016/j.wneu.2012.08.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 06/23/2012] [Accepted: 08/17/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the feasibility of reaching the interpeduncular cistern (IC) through an endoscopic endonasal approach that leaves the pituitary gland in place. METHODS In a series of 10 injected cadaver heads, the transtuberculum ("above") and transclival ("below") approaches were combined, without pituitary transposition. Using 0-degree, 30-degree, and 45-degree endoscopes, the extent of overlap and if a blind spot occurred were determined. Also, the visualization of the IC was compared with the transposition of the pituitary gland approach. Nonparametric statistics were used to evaluate the results. The approach was implemented in 2 patients. RESULTS For both the "above" and "below" views, there was a statistically significant increase in field of view when comparing the 0-degree endoscope with either the 30-degree endoscope (P < 0.05) or the 45-degree endoscope (P < 0.05). There was no difference between the 30-degree endoscope and the 45-degree endoscope (P > 0.05) in the "below" approach, but there was a difference (P < 0.05) in the "above" approach. There was no blind spot with any combination of endoscopes. There was no practical statistically significant difference between the transposition approach and the "above and below" approach. The "above and below" approach was used successfully in 2 surgeries. CONCLUSIONS It is possible to work both "above" and "below" the pituitary gland to reach the IC through an endoscopic endonasal approach. The advantages are the maintenance of normal pituitary and parasellar anatomy and the minimization of the size of the skull base defect. There is no blind spot using this approach that would be revealed with a pituitary transposition. The feasibility of this approach has been confirmed in 2 patients.
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Affiliation(s)
- Danilo Silva
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
| | - Moshe Attia
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
| | - Jothy Kandasamy
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
| | - Marjan Alimi
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
| | - Vijay K Anand
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA
| | - Theodore H Schwartz
- Department of Neurosurgery, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA; Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA; Department of Neurology and Neuroscience, New York Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA.
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Tang CT, Baidya NB, Ammirati M. Endoscope-assisted supraorbital approach to the retroinfundibular area: a cadaveric study. Neurosurg Rev 2012; 36:249-56; 256-7. [PMID: 22895801 DOI: 10.1007/s10143-012-0418-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 05/18/2012] [Accepted: 07/15/2012] [Indexed: 10/28/2022]
Abstract
The purpose of this study is to investigate and evaluate the exposure and maneuverability of this areas provided by an endoscope-assisted supraorbital approach and to compare that to a microscopic supraorbital approach. We exposed microscopically the optico-carotid and the infrachiasmatic windows after a supraorbital craniotomy executed using an eyebrow incision. We then proceeded to explore the retroinfundibular area using these two windows either using the microscope alone or using the endoscope-microscope combination where the microscope was used to (1) guide instrument and endoscope insertion into the surgical field, and (2) explore (with microscopic 3-d vision) subsegments of the endoscopic field of view. We compared the exposure and surgical maneuverability of the approach utilizing the microscopic mode alone with the endoscope-assisted mode. We evaluated the exposure and the surgical maneuverability of key anatomical structures of the retroinfundibular area. The structures evaluated included the diaphragma sellae, the dorsum sellae, the posterior clinoid process, the pituitary stalk, the mammillary bodies, the tuber cinereum, the oculomotor nerves, the basal pons, the upper trunk of the basilar artery, the superior cerebellar arteries, the posterior cerebral arteries, the posterior communicating arteries and the basilar bifurcation. The exposure and the surgical maneuverability were significantly higher in the endoscope-assisted mode (P < 0.0001). Based on our study, the endoscope-assisted supraorbital retroinfundibular approach is associated with larger exposure and maneuverability than the pure microscopic approach. Further clinical information is required to verify the results of this study.
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Affiliation(s)
- Chi-Tun Tang
- Department of Neurological Surgery, Ohio State University Medical Center, N1025 Doan Hall, 410 W. 10th Avenue, Columbus, OH 43210, USA
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Wang F, Sun T, Li X, Xia H, Li Z. Microsurgical and tractographic anatomical study of insular and transsylvian transinsular approach. Neurol Sci 2011; 32:865-74. [PMID: 21863272 PMCID: PMC3171658 DOI: 10.1007/s10072-011-0721-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 07/16/2011] [Indexed: 11/28/2022]
Abstract
This study is to define the operative anatomy of the insula with emphasis on the transsylvian transinsular approach. The anatomy was studied in 15 brain specimens, among five were dissected by use of fiber dissection technique; diffusion tensor imaging of 10 healthy volunteers was obtained with a 1.5-T MR system. The temporal stem consists mainly of the uncinate fasciculus, inferior occipitofrontal fasciculus, Meyer’s loop of the optic radiation and anterior commissure. The transinsular approach requires an incision of the inferior limiting sulcus. In this procedure, the fibers of the temporal stem can be interrupted to various degrees. The fiber dissection technique is a very relevant and reliable method for neurosurgeons to study the details of brain anatomic features. The DTI fiber tracking technique can identify the fiber tracts of the temporal stem. Moreover, it will also help further functional study of human insula.
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Affiliation(s)
- Feng Wang
- Department of Neurosurgery, Affiliated Hospital of Ningxia Medical University, Yinchuan, China
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Jittapiromsak P, Wu A, Nakaji P, Spetzler RF, Preul MC. The challenge of access to the pontomesencephalic junction: an anatomical study of lateral approach and exposure. Skull Base 2011; 20:311-20. [PMID: 21358994 DOI: 10.1055/s-0030-1249571] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We quantitatively compared relative merits of lateral approaches to the pontomesencephalic junction (PMJ): anterior petrosectomy, subtemporal transtentorial, posterior petrosectomy, and retrosigmoid transtentorial. In dissected cadaveric heads, lengths of exposure were measured anteriorly from CN V along the pontomesencephalic sulcus (PMS); posterosuperiorly along the lateral mesencephalic sulcus (LMS); and posteroinferiorly along the interpeduncular sulcus (IPS). Subtemporal transtentorial approach provided best anterior exposure along the PMS (23.8 ± 4.5 mm). Posterosuperior exposures were comparable for all approaches except anterior petrosectomy (limited). Posteroinferior exposure was most with subtemporal transtentorial approach (13.2 ± 2.8 mm). CN V entry/exit point was identified through all approaches, except for subtemporal transtentorial; shortest surgical depth with posterior petrosectomy was 43.7 ± 5.5 mm. PMS-LMS-IPS convergence point: reached through all approaches, except for anterior petrosectomy (limited); shortest surgical depth with posterior petrosectomy was 40.3 ± 4.3 mm. Anterior petrosectomy provides direct anterolateral views of the pons not afforded by subtemporal approach. Subtemporal transtentorial approach provides optimal posterolateral view to the PMJ and cerebellar peduncles. Retrosigmoid transtentorial approach offers wide exposure of the lateral surface, limited on the posteroinferior PMJ by the cerebellum. The small opening of posterior petrosectomy creates an awkward corridor to anterior PMJ targets but provides a direct and shortest route to the cerebellar peduncles.
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Affiliation(s)
- Pakrit Jittapiromsak
- Division of Neurological Surgery, Chulalongkorn Hospital, Chulalongkorn University, Bangkok, Thailand
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Qi ST, Fan J, Zhang XA, Pan J. Reinvestigation of the ambient cistern and its related arachnoid membranes: an anatomical study. J Neurosurg 2011; 115:171-8. [DOI: 10.3171/2011.2.jns101365] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
A precise understanding of the ambient cistern and its associated arachnoid membranes is helpful for accessing perimesencephalic lesions. However, few studies of the arachnoid membranes related to the ambient cistern have been published, and, additionally, some aspects of the ambient cistern also require further examination. The goal of this study was to reinvestigate and expound on the anatomical features of the cistern and membranes.
Methods
The ambient cisterns and its associated arachnoid membranes were examined in 20 adult cadaveric brains using an operative microscope.
Results
The perimesencephalic membrane is a set of inner arachnoid membranes surrounding the midbrain at the level of the tentorial incisura. It arises from the outer arachnoidal membranes covering the tentorial edge and the dorsum sellae and can be subdivided into anterior and posterior portions. The anterior membrane is actually the mesencephalic leaf of Liliequist membrane, which is divided into medial and lateral parts by the oculomotor nerve. The posterior membrane can be divided into horizontal and ascending parts. The ambient cistern is located above the perimesencephalic membrane and contains the anterior choroidal arteries, the posterior cerebral arteries, the basal vein, and sometimes the segments of the superior cerebellar arteries. It communicates with the carotid cistern, the interpeduncular cistern, the oculomotor cistern, the cerebellopontine and cerebellomesencephalic cistern, and the quadrigeminal cistern.
Conclusions
This study updates some information about the ambient cistern and its arachnoid membranes. The perimesencephalic membrane was identified and described in detail. The ambient cistern was verified to be a supratentorial cistern above the perimesencephalic membrane. The borders and contents of this cistern, as well as its relationship with adjacent cisterns, were also redefined.
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Párraga RG, Ribas GC, Andrade SEGL, de Oliveira E. Microsurgical Anatomy of the Posterior Cerebral Artery in Three-Dimensional Images. World Neurosurg 2011; 75:233-57. [DOI: 10.1016/j.wneu.2010.10.053] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 06/23/2010] [Accepted: 10/30/2010] [Indexed: 11/29/2022]
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Wu A, Chang SW, Deshmukh P, Spetzler RF, Preul MC. Through the choroidal fissure: a quantitative anatomic comparison of 2 incisions and trajectories (transsylvian transchoroidal and lateral transtemporal). Neurosurgery 2010; 66:221-8; discussion 228-9. [PMID: 20489509 DOI: 10.1227/01.neu.0000369920.68166.6c] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We compared the transsylvian transchoroidal (TSTC) approach with the lateral transtemporal (LTT) approach. Both approaches proceed through the choroidal fissure but through different incisions and along different trajectories. METHODS Four fixed, silicon-injected heads (8 sides) were used. Nine strategic anatomic points within the dissections were compared between the TSTC and LTT approaches in 7 other silicon-injected heads (14 sides). Neuronavigation was used to gather coordinates from selected points of both approaches to calculate surgical angles and distances to common targets. RESULTS The surgical angle of the TSTC approach for the inferior choroidal point was wider compared with the LTT approach (P < .05). The surgical angles for the P2a-P2p point were similar for both approaches. In the TSTC approach, the P2-P3 point angle was smaller than in the LTT approach (P < .05). The TSTC approach provided (except for the P2-P3 point) significantly shorter distances to all defined anatomic targets compared with the LTT approach. When the posterior cerebral artery was the target in the TSTC approach, the hippocampus was retracted 3 to 8 mm compared with 8 to 13 mm in the LTT approach. CONCLUSION We quantitatively described anatomic features of the TSTC approach and compared them with the LTT approach. For approaching the mesial temporal region, the TSTC approach offers an adequate surgical angle and shorter or similar distances proximal to P2-P3 and requires less temporal lobe and hippocampal retraction than the LTT approach. Such information can help surgeons select the optimal approach to the mesial temporal lobe and its surrounding structures. The TSTC approach should be considered for lesions located in the medial temporal region.
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Affiliation(s)
- Anhua Wu
- Department of Neurosurgery, First Affiliated Hospital of China Medical University, Shenyang, LiaoNing, PR China
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Fernández-Miranda JC, de Oliveira E, Rubino PA, Wen HT, Rhoton AL. Microvascular anatomy of the medial temporal region: part 1: its application to arteriovenous malformation surgery. Neurosurgery 2010; 67:ons237-76; discussion ons276. [PMID: 20679924 DOI: 10.1227/01.neu.0000381003.74951.35] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The medial temporal region (also called the temporomesial or mediobasal temporal region) is the site of the most complex cortical anatomy. OBJECTIVE To investigate the anatomic variability of the arterial supply and venous drainage of each segment of the medial temporal region (MTR), and to discuss and illustrate the implications of the findings for surgery of arteriovenous malformations (AVM) of the MTR. METHODS Forty-seven cerebral hemispheres and 10 silicon-injected cadaveric heads were examined using x3 to x40 magnification. Illustrative surgical cases of MTR AVMs were selected. RESULTS The anterior choroidal artery (AChA) gave rise to an anterior uncal artery in 83% of hemispheres and a posterior uncal or unco-hippocampal artery in 98%. The plexal segment of the AChA gave off neural branches in 38%. The MCA was the site of origin of anterior uncal, unco-parahippocampal, or anterior parahippocampal arteries in 94% of hemispheres. An anterior uncal artery arose from the internal carotid artery (ICA) in 45% of hemispheres. The posterior cerebral artery (PCA) irrigated the entorhinal area through its anterior parahippocampal or hippocampo-parahippocampal branches in every case. A PCA bifurcation was identified in 89% of hemispheres, typically at the middle segment of the MTR. The most common pattern of bifurcation was by division into posteroinferior temporal and parieto-occipital arterial trunks. The anterior segment of the basal vein had a predominant anterior drainage in 35% of hemispheres, and the middle segment had a predominant inferior drainage in 16%. CONCLUSION An understanding of the vascular variability of the MTR is essential for accurate microsurgical resection of MTR AVMs.
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Affiliation(s)
- Juan C Fernández-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Wang H, Zhang R, Yu W, Zhong P, Tan D. The posterior subtemporal keyhole approach combined with the transchoroidal approach to the ambient cistern: microsurgical anatomy and image-guided quantitative analysis. Acta Neurochir (Wien) 2010; 152:1933-42. [PMID: 20852900 DOI: 10.1007/s00701-010-0800-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 09/07/2010] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study is to describe microsurgical anatomy and to quantitatively analyze exposure using the posterior subtemporal keyhole (PSK) approach combined with the transchoroidal keyhole (TCK) approach to the ambient cistern. METHODS We determined the proper location of craniotomy of such combined keyhole approach on 16 sides of cadaver heads. The PSK approach and the TCK approach were performed in the same minicraniotomy to observe microanatomic features and to quantitatively measure exposure limits of the ambient cistern and related structures using image-guided system. RESULTS Some superficial and bone landmarks could be used to find the proper location of such combined minicraniotomy. In the PSK approach, the exposure distances of the trigeminal nerve and the anterior portion of the P2 segment (P2a) were 10.02 ± 0.76 mm and 16.32 ± 2.02 mm, respectively. The superior, inferior, anterior, and posterior exposure limit of brainstem from the intersection point of the lateral mesencephalic sulcus and pontomesencephalic sulcus was 7.5 ± 0.19 mm, 11.04 ± 0.27 mm, 15.72 ± 0.52 mm, and 10.16 ± 0.38 mm, respectively. In the TCK approach, the vertical distances between the taenia fimbriae and the lateral geniculate body without and with mild caudal retraction of the hippocampus were 5.28 ± 0.46 mm and 11.18 ± 0.57 mm, respectively. The linear exposure distances of the posterior portion of the P2 segment (P2p) or P3 segment were 12.14 ± 1.88 mm. Except of one case, the P2p could be exposed using the TCK approach. The midpoint of the medial edge of the parahippocampal gyrus on the coronal magnetic resonance images provides landmark to choose the appropriate approach. CONCLUSIONS The PSK combined with the TCK approach can simultaneously expose the lower and upper ambient cistern in a proper minicraniotomy.
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Affiliation(s)
- Hao Wang
- Department of Neurosurgery, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, People's Republic of China
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Extended endoscopic endonasal approach to the suprasellar parachiasmatic cisterns: anatomic study. Childs Nerv Syst 2010; 26:1161-70. [PMID: 20567834 DOI: 10.1007/s00381-010-1204-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Accepted: 06/12/2010] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The objective of this study is to recognize the available endoscopic routes during approaches to the suprasellar region and the surgical endoscopic anatomy of the related neurovascular structures. MATERIAL AND METHODS Extended endoscopic endonasal approach to the suprasellar region (EEASR) through the planum sphenoidale was performed in five fresh adult cadavers. The anatomic characteristics of the suprasellar parachiasmatic cisterns were studied and documented following the resection of the planum sphenoidale and opening the dura to expose the anterior incisural space. RESULTS Two separate surgical corridors could be used during EEASR: one above and the other below the chiasm. The suprachiasmatic route exposed the gyrus recti, interhemispheric fissure, anterior cerebral artery complex, the lamina terminalis, and through this structure the anterior recess of the third ventricle. The subchiasmatic route exposed the pituitary stalk, superior hypophyseal artery, supraclinoidal internal carotid artery, origin of the ophthalmic artery, anterior choroidal artery, posterior communicating artery, uncus, optic tract, basilar artery and its bifurcation, pons, posterior cerebral artery, superior cerebellar artery, and oculomotor nerve. CONCLUSION The EEASR, a minimally invasive route to suprasellar parachiasmatic area, provided wide exposure of the basal cisterns. The surgical areas that were accessed through the subchiasmatic corridor could be divided into a medial part that included the interpeduncular and prepontine cisterns and a lateral part that contained carotid and sylvian cisterns superiorly and the crural and ambient cisterns inferiorly.
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Abuzayed B, Tanriover N, Gazioglu N, Kafadar AM, Akar Z. Endoscopic anatomy of the oculomotor nerve: defining the blind spot during endoscopic skull base surgery. Childs Nerv Syst 2010; 26:689-96. [PMID: 20012060 DOI: 10.1007/s00381-009-1051-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Accepted: 11/13/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of this study is to define the endoscopic anatomy of the oculomotor nerve (CN III) and its neurovascular relations in order to facilitate surgical procedures and avoid injury to this nerve during endoscopic endonasal approach to the skull base. MATERIALS AND METHODS Endoscopic anatomy of the cavernous sinus was studied in seven fresh adult cadavers bilaterally and the basal cisterns in five fresh adult cadavers. Extended endoscopic endonasal suprasellar approach was performed to expose the oculomotor nerve in the interpeduncular cistern and the endoscopic endonasal transethmoidopterygoidosphenoidal approach to expose the oculomotor nerve within the cavernous sinus. RESULTS The extraorbital part of the oculomotor nerve can be divided into three segments in regard to the cisterns and venous spaces that are being transected: the interpeduncular segment, the cisternal segment, and the intercavernous segment. Of these segments, only the cisternal segment could not be exposed since this segment was located at the initial part of the roof of the cavernous sinus, anterolateral to the posterior clinoid, and posteroinferior to the anterior clinoid processes. Thus, cisternal segment of the oculomotor nerve was considered a blind spot during endoscopic approaches to the skull base. CONCLUSION We defined the endoscopic anatomy of the CN III and the related neurovascular structures and proposed a new segmental classification of extraorbital oculomotor nerve. Awareness of the endoscopic anatomy and the new segmental classification of the CN III may prove helpful in avoiding the risk of nerve injury during endoscopic endonasal surgery for skull base pathologies.
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Affiliation(s)
- Bashar Abuzayed
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Eflatun sok Leylak Sitesi No 12, B Blok, Kat 2, Fenerbahce, Istanbul 34728, Turkey
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