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Shinya Y, Leonel LCPC, Hong S, Moussalem CK, Serioli S, De Bonis A, Nizzola M, Meyer JH, Bauman MMJ, Saez-Alegre M, Kin T, Peris-Celda M, Van Gompel JJ. SupraPetrous InfraTemporal Approach: A Supplemental Approach to Supracerebellar Infratentorial for Inferior Amygdala and Hippocampal Head Access-A Cadaveric Study With Case Illustrations. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01257. [PMID: 39012126 DOI: 10.1227/ons.0000000000001292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/04/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Access to the amygdala and hippocampus (A/H) is complex. To address the limitations and invasiveness of traditional approaches, including the Transsylvian, Subtemporal, and Supracerebellar infratentorial approaches, we developed the suprapetrous infratemporal (SPIT) approach. This study describes the nuances of this approach in both cadaveric studies and clinical cases. METHODS Three unilateral exposures were performed using microscopic and endoscopic methodologies in the SPIT approach. After cadaveric investigation, this approach was successfully implemented in representative clinical cases. RESULTS The SPIT approach enabled direct access to the inferior A/H, circumventing the requirement for temporal lobe retraction and detachment of the temporal lobe from the dura through a subtemporal route by drilling the upper part of the mastoid, consequently mitigating tension on the vein of Labbé. This enabled a bottom-up view because one would gain with a zygomatic osteotomy and forward projection like a mini-posterior petrosal view by using a transmastoid view, without cutting down the zygomatic arch and opening the dura subtemporally, limiting patient pain and preventing case comorbidity. The SPIT approach was performed in 2 cases of mesial temporal cavernoma presenting with seizures. The lesion was visualized intraoperatively and was successfully removed in these cases. The postoperative course was excellent with no complications, and gross total resection was radiographically confirmed with Engel Class 1a seizure freedom. CONCLUSION The SPIT approach is a complementary approach for inferior A/H disease, combining the combined middle fossa approach modified for intradural pathology. Limited drilling of the upper aspect of the mastoid with a medial dural opening at the level of the arcuate eminence provides a direct trajectory with minimal brain retraction. Additional research encompassing a larger patient cohort and extended follow-up periods is required to substantiate the advantages of SPIT in the management of inferior A/H lesions.
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Affiliation(s)
- Yuki Shinya
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Luciano César P C Leonel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Sukwoo Hong
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Simona Serioli
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alessandro De Bonis
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Mariagrazia Nizzola
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Jenna H Meyer
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Megan M J Bauman
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Miguel Saez-Alegre
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Taichi Kin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Maria Peris-Celda
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Oliver T, Kelly A, Vale FL. The Inferior Temporal Gyrus Approach to Mesial Basal Temporal Lobe Surgery: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 26:472-473. [PMID: 37962369 DOI: 10.1227/ons.0000000000000990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/26/2023] [Indexed: 11/15/2023] Open
Affiliation(s)
- Tucker Oliver
- Department of Neurosurgery, Medical College of Georgia, Augusta , Georgia , USA
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Nizzola M, Pompeo E, Torregrossa F, Leonel LCPC, Mortini P, Link MJ, Peris-Celda M. Surgical Anatomy of the Retrosigmoid Approach With Transtentorial Extension: Protecting the 4th Cranial Nerve. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01106. [PMID: 38560788 DOI: 10.1227/ons.0000000000001136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/29/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The retrosigmoid approach with transtentorial extension (RTA) allows us to address posterior cranial fossa pathologies that extend through the tentorium into the supratentorial space. Incision of the tentorium cerebelli is challenging, especially for the risk of injury of the cranial nerve (CN) IV. We describe a tentorial incision technique and relevant anatomic landmarks. METHODS The RTA was performed stepwise on 5 formalin-fixed (10 sides), latex-injected cadaver heads. The porus trigeminus's midpoint, the lateral border of the suprameatal tubercle (SMT)'s base, and cerebellopontine fissure were assessed as anatomic landmarks for the CN IV tentorial entry point, and relative measurements were collected. A clinical case was presented. RESULTS The tentorial opening was described in 4 different incisions. The first is curved and starts in the posterior aspect of the tentorium. It has 2 limbs: a medial one directed toward the tentorium's free edge and a lateral one that extends toward the superior petrosal sinus (SPS). The second incision turns inferiorly, medially, and parallel to the SPS down to the SMT. At that level, the second incision turns perpendicular toward the tentorium's free edge and ends 1 cm from it. The third incision proceeds posteriorly, parallel to the free edge. At the cerebellopontine fissure, the incision can turn toward and cut the tentorium-free edge (fourth incision). On average, the CN IV tentorial entry point was 12.7 mm anterior to the SMT base's lateral border and 20.2 mm anterior to the cerebellopontine fissure. It was located approximately in the same coronal plane as the porus trigeminus's midpoint, on average 1.9 mm anterior. CONCLUSION The SMT and the cerebellopontine fissure are consistently located posterior to the CN IV tentorial entry point. They can be used as surgical landmarks for RTA, reducing the risk of injury to the CN IV.
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Affiliation(s)
- Mariagrazia Nizzola
- Mayo Clinic Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Edoardo Pompeo
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Torregrossa
- Mayo Clinic Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Neurosurgical Unit, Department of Biomedicine, Neurosciences and Advance Diagnostics (BiND), University of Palermo, Palermo, Italy
| | - Luciano César P C Leonel
- Mayo Clinic Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, Vita-Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michael J Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria Peris-Celda
- Mayo Clinic Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Endoscopic-enhanced supra-cerebellar trans-tentorial (SCTT) approach to temporo-mesial region: a multicenter study. Neurosurg Rev 2022; 45:3749-3758. [PMID: 36220960 DOI: 10.1007/s10143-022-01881-6] [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: 06/15/2022] [Revised: 09/03/2022] [Accepted: 09/30/2022] [Indexed: 10/17/2022]
Abstract
Surgical access to the temporo-mesial area may be achieved by several routes such as the sub-temporal, the temporal trans-ventricular, the pterional/trans-sylvian, and the occipital interhemispheric approaches; nonetheless, none of them has shown to be superior to the others. The supra-cerebellar trans-tentorial approach allows a great exposure of the middle and posterior temporo-mesial region, while avoiding temporal lobe retraction. A prospective multicenter study was designed to collect data on patients undergoing endoscopic-enhanced SCTT approach to excise left temporo-mesial lesions. The study involved 5 different neurosurgical European centers and ran from 2015 to 2020. All patients had preoperative as well as postoperative brain MRI and ophthalmology evaluation. A total of 30 patients were included in this study, the mean follow-up was 44 months (range 18 to 84 months), male/female ratio was 16/14, and mean age was 39 years. A gross total resection was achieved in 29/30 (96.7%) cases. All surgical procedures were uneventful, without transient or permanent neurological deficits thanks to the preservation of the posterior cerebral artery. The endoscopic-enhanced SCTT approach provides satisfactory exposure to the left temporo-mesial region. Its minimally invasive nature helps minimize the surgical risks related to vascular and white tract manipulation, which represent known limitations of open microsurgical as well as other approaches.
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Emerson SN, Kadri PADS, Toczylowski M, Al-Mefty O. Inferior is Superior—Transtentorial Transcollateral Sulcus Approach to the Ventricular Atrium: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e369-e370. [DOI: 10.1227/ons.0000000000000433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/29/2022] [Indexed: 11/05/2022] Open
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Rodrigues EM, Isolan GR, Becker LG, Dini LI, Vaz MAS, Frigeri TM. Anatomy of the optic radiations from the white matter fiber dissection perspective: A literature review applied to practical anatomical dissection. Surg Neurol Int 2022; 13:309. [PMID: 35928310 PMCID: PMC9345124 DOI: 10.25259/sni_1157_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 06/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Knowledge of the anatomical course of the optic radiations and its relationship to medial temporal lobe structures is of great relevance in preoperative planning for surgery involving the temporal lobe to prevent damage that may result in postsurgical visual field deficits. Methods: In this anatomical study, we reviewed the literature on this topic and applied the information to practical anatomical dissection. The three-dimensional relationship between the course of the optic radiations and structures accessed in the main microneurosurgical approaches to the medial temporal lobe was examined by applying Klingler’s white matter fiber dissection technique to five formalin-fixed human brains. The dissections were performed with an operating microscope at magnifications of ×3–×40. High-resolution images were acquired during dissection for identification of the anatomical structures, focusing on the characterization of the course of the optic radiations in relation to medial temporal lobe structures. Results: In all five dissected brains, we could expose and clearly define the relationship between the optic radiations and medial temporal lobe structures, improving our understanding of these complex structures. Conclusion: The knowledge gained by studying these relationships will help neurosurgeons to develop risk-adjusted approaches to prevent damage to the optic radiations in the medial temporal region, which may result in a disabling visual field deficit.
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Affiliation(s)
- Eduardo Mello Rodrigues
- Department of Neurosurgery, The Center For Advanced Neurology and Neurosurgery, Brazil (CEANNE),
| | - Gustavo Rassier Isolan
- Department of Neurosurgery, The Center For Advanced Neurology and Neurosurgery, Brazil (CEANNE),
| | - Lia Grub Becker
- Department of Neurosurgery, The Center For Advanced Neurology and Neurosurgery, Brazil (CEANNE),
| | - Leandro Infantini Dini
- Department of Neurosurgery, The Center For Advanced Neurology and Neurosurgery, Brazil (CEANNE),
| | | | - Thomas More Frigeri
- Department of Neurosurgery, Hospital São Lucas - PUCRS, Porto Alegre, Brazil
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7
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Xie T, Wang Y, Zhang X, Shao N, Lu W, Yang Q, Qu C, Li C, Liu T, Liu S, Zhu W. Endoscopic Far-Lateral Supracerebellar Infratentorial Approach for Petroclival Region Meningioma: Surgical Technique and Clinical Experience. Oper Neurosurg (Hagerstown) 2022; 22:290-297. [PMID: 35315837 DOI: 10.1227/ons.0000000000000126] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 11/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The management of petroclival region meningioma remains the ultimate achievement in neurosurgery, because of the formidable technical challenges involved. OBJECTIVE To describe the technique and feasibility of the purely endoscopic far-lateral supracerebellar infratentorial approach (EF-SCITA) for the treatment of petroclival region meningiomas. METHODS We reviewed the clinical data of 10 consecutive cases of petroclival region meningiomas treated with the EF-SCITA from August 2018 to August 2020. The clinical outcomes were analyzed. The patient was placed in the lateral position, and then, a "C" shaped incision and craniotomy with exposed sigmoid and transverse sinuses were performed. With the endoscopic holder, endoscopic procedures were performed using standard 2-hand microsurgical techniques. Whether the tentorium or Meckel cave was handled depended on the tumor extension. RESULTS The mean diameter was 45 × 25 mm. Dizziness and headache were the main symptoms. All 10 patients achieved gross total or subtotal resection (Petroclival Meningioma Grade I-III) with good neurological outcomes. The EF-SCITA provides satisfactory, direct exposure to the petroclival region. Cranial nerve deficits are the main postoperative complications. Two patients had a trochlear nerve injury, 3 patients had transient facial paralysis, and 2 patients had oculomotor paralysis (1 total and 1 incomplete), but both of them recovered during the follow-up period. One patient experienced an ipsilateral superior cerebellar artery infarction, and another patient had transient hemiparesis. CONCLUSION The EF-SCITA is effective for most petroclival region meningiomas, except for the cavernous sinus type. This approach simplifies craniotomy procedures, omits burdensome petrosectomy, and avoids crossing posterior neurovascular structures.
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Affiliation(s)
- Tao Xie
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Cancer Center, Shanghai Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yushe Wang
- Department of Neurosurgery, Henan Provincial Peoples Hospital, Zhengzhou, Henan Province, China
| | - Xiaobiao Zhang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Cancer Center, Shanghai Zhongshan Hospital, Fudan University, Shanghai, China.,Digital Medical Research Center, Fudan University, Shanghai, China
| | - Naiyuan Shao
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, Jiangsu Province, China
| | - Weicheng Lu
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Qiaoqiao Yang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chenghui Qu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chen Li
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tengfei Liu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shuang Liu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wei Zhu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
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Strickland BA, Zada G. Commentary: Infra-Occipital Supra-Tentorial Approach for Resection of Low-Grade Tumor of the Left Lingual Gyrus: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E261-E262. [PMID: 34114038 DOI: 10.1093/ons/opab178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/04/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ben A Strickland
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, California, USA
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9
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Almeida JP, Quinones-Hinojosa A, Dagi TF. Commentary: Evandro de Oliveira in the Historical Context of Brazilian Neurosurgery. Neurosurgery 2021; 89:E264-E265. [PMID: 34392361 DOI: 10.1093/neuros/nyab313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 06/28/2021] [Indexed: 11/13/2022] Open
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10
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Luther E, Kaur G, Komotar R, Ivan ME. Commentary: Infra-Occipital Supra-Tentorial Approach for Resection of Low-Grade Tumor of the Left Lingual Gyrus: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E259-E260. [PMID: 34270754 DOI: 10.1093/ons/opab210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/04/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Evan Luther
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Gurvinder Kaur
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ricardo Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.,Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.,Sylvester Comprehensive Cancer Center, Miami, Florida, USA
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Kikuta Y, Yamaguchi K, Ishikawa T, Funatsu T, Okada Y, Kawamata T. Selection of approach and bypass for fetal-type posterior cerebral artery aneurysm: illustrative cases. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE21240. [PMID: 35855078 PMCID: PMC9245774 DOI: 10.3171/case21240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/29/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Unlike in aneurysms of the adult-type posterior cerebral artery (PCA), in aneurysms of the fetal-type PCA, parent artery occlusion (PAO) results in vascular insufficiency and major ischemic strokes. Preservation or reconstruction of fetal-type PCAs is necessary to prevent these complications. Furthermore, it is necessary to select an appropriate bypass method and approach for revascularization of the PCA. OBSERVATIONS The authors report 2 cases of aneurysms of fetal-type PCAs that were successfully treated with PAO with revascularization. A 38-year-old man with a large unruptured right PCA aneurysm at the postcommunicating (P2) segment underwent trapping with superficial temporal artery–PCA bypass via the anterior temporal and subtemporal approaches. In addition, a 45-year-old woman with a left PCA aneurysm at the quadrigeminal (P3)–cortical (P4) segments resulting in subarachnoid hemorrhage underwent proximal clipping of the P3 segment via the occipital interhemispheric approach with an occipital artery–PCA bypass. Although she had perforator infarction, major ischemic stroke was prevented, and aneurysm occlusion was accomplished in both cases. LESSONS Aneurysms of fetal-type PCAs pose a risk of ischemia due to PAO. The combined use of bypass and revascularization should be considered to prevent major ischemic stroke after occlusion of the fetal-type PCA. However, perforator infarction is a concern.
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Affiliation(s)
- Yoshichika Kikuta
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Koji Yamaguchi
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Tatsuya Ishikawa
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Takayuki Funatsu
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yoshikazu Okada
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
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De Benedictis A, de Palma L, Herur-Raman A, Pepi C, Colafati GS, Carboni A, Randi F, Savioli A, Ricci G, Mastronuzzi A, Carai A, Specchio N, Marras CE. Infra-Occipital Supra-Tentorial Approach for Resection of Low-Grade Tumor of the Left Lingual Gyrus: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E257-E258. [PMID: 34022047 DOI: 10.1093/ons/opab172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/19/2021] [Indexed: 11/13/2022] Open
Abstract
Surgical treatment of lesions involving the postero-medial occipito-temporal region is challenging because of high risk of morbidity due to damage or excessive retraction of critical neuro-vascular structures, especially within the dominant hemisphere.1-3 Here, we describe the case of a 17-yr-old patient who underwent resection of an epileptogenic low-grade tumor located within the left-dominant lingual gyrus. Seizures were characterized, as a first symptom, by right-sided simple visual hallucination that pointed to the left pericalcarine region, corresponding to the lesion location. No signs of primary involvement of anterior temporo-mesial structures (hippocampus/amygdala) were found. As the anatomo-electroclinical correlation was concordant, direct tumor removal was indicated through an infra-occipital supratentorial approach. This route allowed direct access to the target through a safe extra-axial corridor, which limits intraparenchymal dissection until the tumor margin is identified and avoids critical vascular structures, such as the vein of Labbé.4,5 An external cerebrospinal fluid (CSF) drainage was used to facilitate brain relaxation, minimizing brain and venous retraction and, consequently, reducing the risk of postoperative neurological complications, especially for vision. Postoperative magnetic resonance imaging (MRI) demonstrated no surgical complications. Pathological examination revealed a ganglioglioma. At 9-mo follow-up, the neurological examination was normal, antiepileptic therapy was stopped, and the patient was seizure-free. The video describes the main surgical steps, using both intraoperative videos and advanced 3-dimensional modeling of neuroimaging pictures. Informed consent was obtained for surgery and video recording.
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Affiliation(s)
- Alessandro De Benedictis
- Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Luca de Palma
- Neurology Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Aalap Herur-Raman
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Chiara Pepi
- Neurology Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Alessia Carboni
- Neuroradiology Unit, Imaging Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Franco Randi
- Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandra Savioli
- Intensive Care Unit, Department of Emergency, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giuseppe Ricci
- Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Angela Mastronuzzi
- Department of Haematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrea Carai
- Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Nicola Specchio
- Neurology Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Carlo Efisio Marras
- Neurosurgery Unit, Department of Neurosciences, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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López López LB, Moles Herbera JA, Vázquez Sufuentes S, Fustero de Miguel D, Avedillo Ruidíaz A, Orduna Martínez J, Pellejero JC. Supracerebellar transtentorial approach for left parahippocampal cavernous malformation. Surg Neurol Int 2021; 12:216. [PMID: 34084643 PMCID: PMC8168674 DOI: 10.25259/sni_166_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/05/2021] [Indexed: 11/08/2022] Open
Abstract
Background: Lesions in the temporomesial region can be reached by various approaches: subtemporal, transsylvian, transcortical, interhemispheric parieto-occipital, or supracerebellar transtentorial (SCTT). The choice varies according to the characteristics of the lesion and neighboring structures. Case Description: In this clinical case, it is presented a 56-year-old man with long-term evolution of drug-resistant epilepsy secondary to a cavernoma in the left parahippocampal gyrus. After assessing the lesion, it was decided a SCTT approach for its resection in a semi-sitting position, to avoid language disorders or visual damage. The surgery was uneventful and the patient did not present epileptic seizures during 6-month follow-up. Conclusion: Performing a SCTT is safe and feasible option for resection of lesions located in the basal temporomesial region without causing damage to neighboring structures, especially those located in the middle and posterior two-thirds of temporal region.
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González-López P, Luna E, Abarca-Olivas J, Daniel RT. How I do it: paramedian supracerebellar transtentorial approach for a temporomesial glioma. Acta Neurochir (Wien) 2021; 163:1311-1316. [PMID: 33786685 DOI: 10.1007/s00701-021-04825-z] [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: 01/19/2021] [Accepted: 03/22/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Classical approaches to the temporomesial region (TMR) include transtemporal, transylvian, or subtemporal. The supracerebellar infratentorial, initially developed to access dorsolateral cavernomas, has of late shown its versatility to access areas around the central core. The TMR is one such area that can be accessed through this approach with the addition of a tentorial incision. METHOD The paramedian supracerebellar transtentorial approach (PSCTA) is described along with its advantages and limits compared to other approaches to treat TMR gliomas. CONCLUSION The PSCTA offers a basal panoramic view of the TMR without the need of retraction, cortical incision, and white matter transgression.
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Affiliation(s)
- Pablo González-López
- Department of Neurosurgery, Hospital General Universitario de Alicante, Avda. Pintor Baeza sn, 03010, Alicante, Spain.
| | - Enrique Luna
- Department of Neurosurgery, Hospital General Universitario de Alicante, Avda. Pintor Baeza sn, 03010, Alicante, Spain
| | - Javier Abarca-Olivas
- Department of Neurosurgery, Hospital General Universitario de Alicante, Avda. Pintor Baeza sn, 03010, Alicante, Spain
| | - Roy T Daniel
- Department of Neurosurgery, CHUV, Lausanne, Switzerland
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Wang P, Hameed NUF, Chong ST, Fan W, Zhu K, Li W, Lin CP, Feng R, Wu J. The basal turning point of optic radiation (bTPOR): The location of optic radiation in the cerebral basal surface. Clin Neurol Neurosurg 2021; 203:106562. [PMID: 33631507 DOI: 10.1016/j.clineuro.2021.106562] [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: 12/31/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUNDS Optic radiation protection is crucial in the basal temporal approach to the mesial temporal lobe. Clear description of the optic radiation in the basal brain surface is lacking. Our aim is to describe the anatomy of optic radiation in the basal cerebral surface and define safety zone of basal temporal approach avoiding of optic radiation injury. METHODS Five brain specimens (10 hemispheres) were dissected using Klingler method to observe the course of the optic radiation. Diffusion tensor imaging data of 25 volunteers were used to verify the fiber dissection results. The relationship of the optic radiation to nearby structures were illustrated and measured. RESULTS The optic radiation bends from the lateral wall of the lateral ventricle to its bottom at a basal turning point of optic radiation (bTPOR). The bTPOR is at the plane crossing the center point of the splenium of corpus callosum. MRI measurements showed no significant difference in the distance from the center of the splenium of corpus callosum and the bTPOR to the occipital pole (59.46 ± 4.338 mm vs 59.54 ± 3.805 mm, p = 0.95). Anterior to bTPOR, no optic radiation fibers were found at the basal brain surface. CONCLUSIONS The bTPOR was found as a landmark of the optic radiation in the cerebral basal surface. With neuronavigation, the splenium of corpus callosum can be a landmark of the bTPOR. By approaching mesial temporal lesions using the basal temporal approach anterior to bTPOR, optic radiation injury can be prevented.
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Affiliation(s)
- Peng Wang
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - N U Farrukh Hameed
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Shin Tai Chong
- Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan
| | - Wenke Fan
- Department of Human Anatomy and Histoembryology, School of Basic Medical Science, Fudan University, Shanghai, China
| | - Keming Zhu
- Department of Human Anatomy and Histoembryology, School of Basic Medical Science, Fudan University, Shanghai, China
| | - Wensheng Li
- Department of Human Anatomy and Histoembryology, School of Basic Medical Science, Fudan University, Shanghai, China
| | - Ching-Po Lin
- Institute of Neuroscience, National Yang-Ming University, Taipei, Taiwan; Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China
| | - Rui Feng
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China.
| | - Jinsong Wu
- Glioma Surgery Division, Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China; Brain Function Laboratory, Department of Neurosurgery, Fudan University, Shanghai, China; Institute of Brain-Intelligence Technology, Zhangjiang Lab, Shanghai, China
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Comparison of the keyhole trans-middle temporal gyrus approach and transsylvian approach for selective amygdalohippocampectomy: A single-center experience. J Clin Neurosci 2020; 81:390-396. [PMID: 33222948 DOI: 10.1016/j.jocn.2020.10.019] [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: 06/09/2020] [Revised: 09/19/2020] [Accepted: 10/03/2020] [Indexed: 01/19/2023]
Abstract
Several approach routes exist for selective amygdalohippocampectomy (SAH); however, previous reports regarding a comparison of these routes are limited. Here, we compared trans-middle temporal gyrus (T2) SAH and transsylvian (TS) SAH in terms of seizure outcome, visual-field defect, memory function, and operation time in our institution. This retrospective study examined the data of 16 patients with medically intractable mesial temporal lobe epilepsy. Six patients underwent trans-T2 SAH and 10 patients underwent TS SAH between July 2014 and February 2019 in Osaka City University Hospital. In trans-T2 SAH, we performed a keyhole temporal craniotomy and a small corticotomy on T2. In TS SAH, we performed a 1.5 cm corticotomy along the inferior periinsular sulcus after opening the sylvian fissure. Amygdalohippocampectomy after reaching the inferior horn of the lateral ventricle was performed in the same manner in both procedures. The seizure outcome, visual-field defect, memory function, and operation time were retrospectively compared between the procedures. Seizure-free outcomes were achieved for six patients in the trans-T2 SAH and eight patients in the TS SAH group. There were no significant differences in the seizure outcome, visual-field defect, and memory function. The operation time was significantly shorter for trans-T2 SAH than TS SAH. The postoperative scar was less conspicuous for trans-T2 SAH. Trans-T2 SAH and TS SAH were comparable in terms of the seizure outcome, visual-field defect, and memory function. The operation time and length of the skin incision were shorter for trans-T2 SAH, suggesting that it may be preferable for general epilepsy surgeons.
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Rosenblum JS, Tunacao JM, Chandrashekhar V, Jha A, Neto M, Weiss C, Smirniotopoulos J, Rosenblum BR, Heiss JD. Tentorial Venous Anatomy: Variation in the Healthy Population. AJNR Am J Neuroradiol 2020; 41:1825-1832. [PMID: 33023913 DOI: 10.3174/ajnr.a6775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/02/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE A new transtentorial venous system consisting of medial, intermediate, and lateral tentorial veins, connecting infra- and supratentorial compartments, was recently shown in 2 cadaver dissections and 2 patient scans. We sought to characterize the venous patterns within the tentorium and their relation to measures of skull development in a cohort of healthy adults. MATERIALS AND METHODS We retrospectively reviewed tentorial venous anatomy of the head using CTA/CTV performed for routine care or research purposes in 238 patients. Included studies had adequate contrast opacification of venous structures and a section thickness of ≤2 mm; we excluded cases with space-occupying lesions and vascular pathologies. Tentorial angle, dural sinus configurations, and measures of skull base development were assessed as predictors of tentorial venous anatomy variation via Cramér V association, the binary encoded Pearson correlation, and nearest-point algorithm with the Euclidean distance metric for clustering. RESULTS Tentorial vein development was related to the ringed configuration of the tentorial sinuses (P < .005). There were 3 configurations. Groups 1A and 1B (n = 50/238) had ringed configuration, while group 2 did not (n = 188/238). Group 1A (n = 38/50) had a medialized ringed configuration, and group 1B had a lateralized ringed configuration (n = 12/50). Measurements of skull base development were predictive of these groups. The ringed configuration of group 1 was related to the presence of a split confluens, which correlated with a decreased internal auditory canal-petroclival fissure angle. Configuration 1A was related to the degree of petrous apex pneumatization (P value = .010). CONCLUSIONS Variations in the transtentorial venous system directly correlate with cranial development.
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Affiliation(s)
- J S Rosenblum
- Surgical Neurology Branch (J.S.R., J.D.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland .,Neuro-Oncology Branch (J.S.R.), National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - J M Tunacao
- Department of Radiology and Radiological Science (J.M.T., C.W.), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - A Jha
- Section on Medical Neuroendocrinology (A.J.), Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - M Neto
- Department of Neurosurgery (M.N.), Hospital Beneficência Portuguesa de São Paulo, Institute of Neurological Science of São Paulo Bela Vista, São Paulo, Brazil
| | - C Weiss
- Department of Radiology and Radiological Science (J.M.T., C.W.), The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - J Smirniotopoulos
- Department of Radiology (J.S.), George Washington University, Washington, DC.,MedPix® (J.S.), National Library of Medicine, Bethesda, Maryland
| | - B R Rosenblum
- Department of Neurosurgery (B.R.R.), Riverview Medical Center, Red Bank, New Jersey
| | - J D Heiss
- Surgical Neurology Branch (J.S.R., J.D.H.), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
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Baranoski JF, Bajaj A, Przybylowski CJ, Catapano JS, Frisoli FA, Lang MJ, Lawton MT. Clip retraction of the tentorium: application of a novel technique for tentorial retraction during supracerebellar transtentorial approaches. J Neurosurg 2020; 134:1198-1202. [PMID: 32330880 DOI: 10.3171/2020.2.jns192952] [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: 10/30/2019] [Accepted: 02/04/2020] [Indexed: 11/06/2022]
Abstract
Supracerebellar transtentorial (SCTT) approaches have become a popular option for treatment of a variety of pathologies in the medial and basal temporal and occipital lobes and thalamus. Transtentorial approaches provide numerous advantages over transcortical approaches, including obviating the need to traverse eloquent cortex, not requiring parenchymal retraction, and circumventing critical vascular structures. All of these approaches require a tentorial opening, and numerous techniques for retraction of the incised tentorium have been described, including sutures, fixed retractors, and electrocautery. However, all of these techniques have considerable drawbacks and limitations. The authors describe a novel application of clip retraction of the tentorium to the supracerebellar approaches in which an aneurysm clip is used to suspend the tentorial flap, and an illustrative case is provided. Clip retraction of the tentorium is an efficient, straightforward adaptation of an established technique, typically used for subtemporal approaches, that improves visualization and surgical ergonomics with little risk to nearby venous structures. The authors find this technique particularly useful for the contralateral SCTT approaches.
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Candanedo C, Moscovici S, Spektor S. The infratranstentorial subtemporal approach (ITSTA): a valuable skull base approach to deep-seated non-skull base pathology. Acta Neurochir (Wien) 2019; 161:2335-2342. [PMID: 31486891 DOI: 10.1007/s00701-019-04050-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 08/22/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgical access to space-occupying lesions such as tumors and vascular malformations located in the area of the tentorial notch, mediobasal temporal lobe, and para-midbrain is difficult. Lesions in this area are typically resected with supratentorial approaches demanding significant elevation of the temporal lobe or even partial lobectomy, or via a supracerebellar transtentorial approach. We introduce an alternative, the skull base infratranstentorial subtemporal approach (ITSTA), which provides excellent exposure of the incisural area while minimizing risk to the temporal lobe. METHODS We included consecutive patients with pathology involving the area of the tentorial incisura, para-midbrain, and mediobasal temporal area who underwent surgery via ITSTA from 2012 to 2018. The approach includes partial mastoidectomy, temporal craniotomy, and tentorial section. Space obtained by mastoidectomy provides a sharp high-rising angle-of-attack, significantly diminishing the need for temporal lobe retraction. Surgeries were performed using microsurgical techniques, neuronavigation, and electrophysiological monitoring. Clinical presentation, tumor characteristics, extent of resection, complications, and outcome were retrospectively reviewed under a waiver of informed consent. RESULTS Nine patients met inclusion criteria (five female, four male; mean age 44 years, range 7-72). They underwent surgery for removal of para-midbrain arteriovenous malformation (AVM, 3/9), medial tentorial meningioma (2/9), mediobasal epidermoid cyst (2/9), oculomotor schwannoma (1/9), or pleomorphic xanthoastrocytoma (PXA) of the fusiform gyrus (1/9). Three AVMs were removed completely; among six patients with tumors, gross total resection was achieved in three and subtotal resection in three. All surgeries were uneventful without complications. There were no new permanent neurological deficits. At late follow-up (mean 42.5 months), eight patients had a Glasgow Outcome Score (GOS) of 5. One 66-year-old female died 18 months after surgery for reasons not related to her disease or surgery. CONCLUSIONS The ITSTA is a valuable skull base approach for removal of non-skull base pathologies located in the difficult tentorial-incisural parabrainstem area.
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Affiliation(s)
- Carlos Candanedo
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel
| | - Samuel Moscovici
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel
| | - Sergey Spektor
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel.
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Uchino H, Akioka N, Tomita T, Kashiwazaki D, Kuwayama N, Kuroda S. Removal of superior vermian arteriovenous malformation through the occipital transtentorial approach. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Golub D, Mehan ND, Kwan K, Salas SJ, Schulder M. Supracerebellar Transtentorial Approach for Occipital Meningioma to Maximize Visual Preservation: Technical Note. Oper Neurosurg (Hagerstown) 2018; 17:E177-E183. [DOI: 10.1093/ons/opy380] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 11/18/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE
Surgery for resection of tentorial meningiomas compressing primary visual cortex carries a significant risk of worsening vision. This concern is especially acute in patients with a preexisting visual deficit. Approaches that involve mechanical retraction of the occipital lobe further threaten visual function. The supracerebellar transtentorial (SCTT) approach, which does not carry a risk of occipital retraction injury, should be considered for patients with occipital tentorial meningiomas to maximize functional visual outcomes.
CLINICAL PRESENTATION
A 54-yr-old woman underwent 2 resections and radiation therapy for a right occipital oligodendroglioma as a teenager. She was left with a complete left homonymous hemianopsia. The patient now presented with progressive vision loss in her remaining right visual field. Imaging revealed a left occipital superiorly projecting tentorial meningioma. To preserve her remaining visual function the SCTT approach was chosen for resection. A Simpson grade 1 removal was achieved without disrupting the occipital lobe pia or requiring mechanical cerebellar retraction. A diagnosis of a WHO grade II meningioma (presumably radiation induced) was made. The patient's vision returned to premorbid baseline 1 wk after surgery.
CONCLUSION
The SCTT approach should be considered for the surgical management of patients with occipital tentorial meningiomas when visual preservation is at risk. This approach avoids transgression of visual cortex and minimizes the risk of venous infarction or contusions from retraction injury.
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Affiliation(s)
- Danielle Golub
- Department of Neurosurgery, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
- Department of Neurosurgery, Department of Neurology, New York University School of Medicine, New York, New York
| | - Neal D Mehan
- Department of Neurosurgery, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Kevin Kwan
- Department of Neurosurgery, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Sussan J Salas
- Department of Neurosurgery, Henry Ford Hospital System, Detroit, Michigan
| | - Michael Schulder
- Department of Neurosurgery, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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Gonçalves-Ferreira A, Rainha-Campos A, Franco A, Pimentel J, Bentes C, Peralta AR, Morgado C. Amygdalohippocampotomy for mesial temporal lobe sclerosis: Epilepsy outcome 5 years after surgery. Acta Neurochir (Wien) 2017; 159:2443-2448. [PMID: 28849383 DOI: 10.1007/s00701-017-3305-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 08/15/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND The goal of the present study is the evaluation of the long-term clinical outcome of epilepsy in patients with mesial temporal lobe sclerosis (MTLS) submitted to amygdalohippocampotomy (AHCo). AHCo consists of the lateral ablation of the amygdala and the peri-hippocampal disconnection instead of amygdalohippocampectomy (AHC), which involves the removal of both structures. We previously reported the short-term results of AHCo, so we here present the long-term results (> 5 years of follow-up) of the patients operated on with AHCo. METHOD Since 2007, 35 patients (22 females) aged 20-61 years (mean: 42 years) were operated on with the AHCo technique, 17 patients on the left side and 18 on the right. Of these patients, 21 (14 females) have been followed up > 5 years (5 to 7.5 years, mean 6.5 years). We compare the present results with those observed shortly after surgery and with the patients operated on with AHC. FINDINGS In all 21 cases, the diagnosis was mesial temporal lobe sclerosis (histology confirmed in 20), 11 on the left side and 10 on the right. Epilepsy results after 5 years were good/very good in 18 patients (85.7%), with Engel class IA-B in 15 (71.4%) and II in 3 (14.3%), and bad in 3 patients, with Engel Class III in 2 (9.5%) and class IV in 1 (4.8%). Concerning morbidity, one patient had hemiparesis (hypertensive capsular hemorrhage 24 h after surgery), two verbal memory worsening, two quadrantanopia and three late depression that was reversed with medication. Comparatively, the AHC long-term results were 87% Engel class I, 8% Engel class II and 5% Engel class III-IV. The morbidity was equally small. CONCLUSIONS The good/very good results of AHCo 5 years after surgery are 86%, which is not distinct from the AHC results. So AHCo seems to be effective and potentially safer than AHC in long-term follow-up.
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Affiliation(s)
- Antonio Gonçalves-Ferreira
- Department of Neurosurgery, Refractory Epilepsy Reference Center, Department of Neurosciences, University Hospital Santa Maria (CHLN-EPE), Lisbon, Portugal.
| | - Alexandre Rainha-Campos
- Department of Neurosurgery, Refractory Epilepsy Reference Center, Department of Neurosciences, University Hospital Santa Maria (CHLN-EPE), Lisbon, Portugal
| | - Ana Franco
- Department of Neurology, EEG Laboratory, Refractory Epilepsy Reference Center, Department of Neurosciences, University Hospital Santa Maria (CHLN-EPE), Lisbon, Portugal
| | - Jose Pimentel
- Department of Neurology, Neuropathology Laboratory, Refractory Epilepsy Reference Center, Department of Neurosciences, University Hospital Santa Maria (CHLN-EPE), Lisbon, Portugal
| | - Carla Bentes
- Department of Neurology, EEG Laboratory, Refractory Epilepsy Reference Center, Department of Neurosciences, University Hospital Santa Maria (CHLN-EPE), Lisbon, Portugal
| | - Ana-Rita Peralta
- Department of Neurology, EEG Laboratory, Refractory Epilepsy Reference Center, Department of Neurosciences, University Hospital Santa Maria (CHLN-EPE), Lisbon, Portugal
| | - Carlos Morgado
- Department of Neurological Imaging, Refractory Epilepsy Reference Center, Department of Neurosciences, University Hospital Santa Maria (CHLN-EPE), Lisbon, Portugal
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Talacchi A, Biroli A, Medaglia S, Locatelli F, Meglio M. Surgical Management of Anterolateral and Posteromedial Incisural Tentorial Meningioma. Oper Neurosurg (Hagerstown) 2017; 15:120-130. [DOI: 10.1093/ons/opx228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 09/27/2017] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Tentorial meningiomas are a broad and consistent category of tumors but their definition is still unclear and their classification uncertain.
OBJECTIVE
To report the clinical and surgical characteristics of tentorial hiatus meningiomas based on a revised classification of tentorial meningiomas.
METHODS
We reviewed the records of 14 patients who had undergone microsurgical removal of incisural tentorial meningioma. Two tumor subgroups, anterolateral (AL) and posteromedial (PM), were distinguished according to their site of attachment: the middle third and the posterior third of the tentorial free margin, respectively. Clinical presentation, radiological findings, surgical approaches, extent of resection, and outcome were compared.
RESULTS
The 2 subgroups differed by tumor size (larger in PM), incidence of the direction of growth (infratentorial in PM), and hydrocephalus (only in PM), as well as by some clinical aspects. Surgical approach depended on tumor location: lateral (pterional, subtemporal, and retromastoid) for AL lesions; medial (occipital or supracerebellar infratentorial) for PM lesions. Total removal (Simpson grade I-II) was performed in 64% of cases and complications occurred in 14%. Stereotactic radiosurgery was performed in cases of incomplete resection. At a mean follow-up of 104.5 mo, clinical improvement with low recurrence (9%) was achieved.
CONCLUSION
Reallocation of tentorial edge meningiomas is the premise to compare treatment and further improve the approach case-by-case. In spite of their deep site, good outcomes can be achieved in both AL and PM tentorial meningiomas. Also of note is the indolent behavior of residual tumor.
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Affiliation(s)
- Andrea Talacchi
- Department of Neurosciences, Biomedi-cine and Movement Sciences, Section of Neurosurgery, University of Verona, Italy
| | - Antonio Biroli
- Department of Neurosciences, Biomedi-cine and Movement Sciences, Section of Neurosurgery, University of Verona, Italy
- Department of Neurosurgery, Hospital Eugenio Espejo, Quito, Ecuador
| | - Stefano Medaglia
- Department of Neurosciences, Biomedi-cine and Movement Sciences, Section of Neurosurgery, University of Verona, Italy
| | - Francesca Locatelli
- Department of Neurosciences, Biomedi-cine and Movement Sciences, Section of Neurosurgery, University of Verona, Italy
- Department of Public Health and Community Medicine, Section of Epidemiology and Medical Statistics, University of Verona, Verona, Italy
| | - Mario Meglio
- Department of Neurosciences, Biomedi-cine and Movement Sciences, Section of Neurosurgery, University of Verona, Italy
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Campero A, Ajler P, Rica C, Rhoton A. Cavernomas and Arteriovenous Malformations in the Mesial Temporal Region: Microsurgical Anatomy and Approaches. Oper Neurosurg (Hagerstown) 2017; 13:113-123. [PMID: 28931254 DOI: 10.1227/neu.0000000000001239] [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: 07/17/2015] [Accepted: 12/26/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The mesial temporal region (MTR) is located deep in the temporal lobe and it is surrounded by important vascular and nervous structures that should be preserved during surgery. OBJECTIVE To describe microsurgical anatomy and approaches to the MTR in relation to cavernomas and arteriovenous malformations (AVMs). METHODS Five formalin-fixed and red silicone-embedded heads of adult cadavers were used for this study. Between January 2003 and June 2014, 7 patients with cavernomas and 6 patients with AVMs in the MTR underwent surgery. RESULTS The MTR of the cadavers was divided into 3 areas: anterior, middle, and posterior. Of the 7 patients with MTR cavernomas, 4 were located anteriorly, 2 were located medially, and 1 was located posteriorly. Of the 6 patients with MTR AVMs, 3 were located in the anterior sector, 2 in the middle sector, and 1 in the posterior sector. For the anterior portion of the MTR, a transsylvian-transinsular approach was used; for the middle portion of the MTR, a transtemporal approach was used (anterior temporal lobectomy); and for the posterior portion of the MTR, a supracerebellar-transtentorial approach was used. CONCLUSION Dividing the MTR into 3 regions allows us to adapt the approach to lesion location. Thus, the anterior sector can be approached via the sylvian fissure, the middle sector can be approached transtemporally, and the posterior sector can be approached via the supracerebellar approach.
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Affiliation(s)
- Alvaro Campero
- Department of Neurological Surgery, Hospital Padilla, Tucumán, Argentina.,Department of Neurological Surgery, University of Florida, Gainesville, Florida
| | - Pablo Ajler
- Department of Neurological Surgery, Hospital Italiano, Buenos Aires, Argentina
| | - Carlos Rica
- Department of Neurological Surgery, Sanatorio Güemes, Buenos Aires, Argentina
| | - Albert Rhoton
- Department of Neurological Surgery, University of Florida, Gainesville, Florida
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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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Efficacy of the transtemporal approach with awake brain mapping to reach the dominant posteromedial temporal lesions. Acta Neurochir (Wien) 2017; 159:177-184. [PMID: 27888341 DOI: 10.1007/s00701-016-3035-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 11/15/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgeries for lesions in the dominant hippocampal and parahippocampal gyrus involving the posteromedial temporal regions are challenging to perform because they are located close to Wernicke's area; white matter fibers related with language; the optic radiations; and critical neurovascular structures. We performed a transtemporal approach with awake functional mapping for lesions affecting the dominant posteromedial temporal regions. The aim of this study was to assess the feasibility, safety, and efficacy of awake craniotomy for these lesions. METHODS We retrospectively reviewed four consecutive patients with tumors or cavernous angiomas located in the left hippocampal and parahippocampal gyrus, which further extended to the posteromedial temporal regions, who underwent awake surgery between December 2014 and January 2016. RESULTS Four patients with lesions associated with the left hippocampal and parahippocampal gyrus, including the posteromedial temporal area, who underwent awake surgery were registered in the study. In all four patients, cortical and subcortical eloquent areas were identified via direct electrical stimulation. This allowed determination of the optimal surgical route to the angioma or tumor, even in the language-dominant hippocampal and parahippocampal gyrus. In particular, this approach enabled access to the upper part of posteromedial temporal lesions, while protecting the subcortical language-related fibers, such as the superior longitudinal fasciculus. CONCLUSIONS This study revealed that awake brain mapping can enable the safe resection of dominant posteromedial temporal lesions, while protecting cortical and subcortical eloquent areas. Furthermore, our experience with four patients demonstrates the feasibility, safety, and efficacy of awake surgery for these lesions.
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Kadri PAS, de Oliveira JG, Krayenbühl N, Türe U, de Oliveira EPL, Al-Mefty O, Ribas GC. Surgical Approaches to the Temporal Horn: An Anatomic Analysis of White Matter Tract Interruption. Oper Neurosurg (Hagerstown) 2016; 13:258-270. [DOI: 10.1093/ons/opw011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 10/20/2016] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND: Surgical access to the temporal horn is necessary to treat tumors and vascular lesions, but is used mainly in patients with mediobasal temporal epilepsy. The surgical approaches to this cavity fall into 3 primary categories: lateral, inferior, and transsylvian. The current neurosurgical literature has underestimated the interruption of involved fiber bundles and the correlated clinical manifestations.
OBJECTIVE: To delineate the interruption of fiber bundles during the different approaches to the temporal horn.
METHODS: We simulated the lateral (trans-middle temporal gyrus), inferior (transparahippocampal gyrus), and transsylvian approaches in 20 previously frozen, formalin-fixed human brains (40 hemispheres). Fiber dissection was then done along the lateral and inferior aspects under the operating microscope. Each stage of dissection and its respective fiber tract interruption were defined.
RESULTS: The lateral (trans-middle temporal gyrus) approach interrupted “U” fibers, the superior longitudinal fasciculus (inferior arm), occipitofrontal fasciculus (ventral segment), uncinate fasciculus (dorsolateral segment), anterior commissure (posterior segment), temporopontine, inferior thalamic peduncle (posterior fibers), posterior thalamic peduncle (anterior portion), and tapetum fibers. The inferior (transparahippocampal gyrus) approach interrupted “U” fibers, the cingulum (inferior arm), and fimbria, and transected the hippocampal formation. The transsylvian approach interrupted “U” fibers (anterobasal region of the extreme capsule), the uncinate fasciculus (ventromedial segment), and anterior commissure (anterior segment), and transected the anterosuperior aspect of the amygdala.
CONCLUSION: White matter dissection improves our knowledge of the complex anatomy surrounding the temporal horn. Identifying the fiber bundles at risk during each surgical approach adds important information for choosing the appropriate surgical strategy.
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Affiliation(s)
- Paulo A. S. Kadri
- Division of Neurosurgery, School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande-MS, Brazil
- Clinical Anatomy Discipline, Department of Surgery, University of São Paulo Medical School (FMUSP), São Paulo, Brazil
| | - Jean G. de Oliveira
- Division of Cerebrovas-cular and Skull Base Surgery, Center of Neurology and Neurosurgery Associates (CENNA), Hospital Beneficência Por-tuguesa de São Paulo-SP, Brazil
| | | | - Uğur Türe
- Department of Neurosurgery, Yeditepe University, Istanbul, Turkey
| | - Evandro P. L. de Oliveira
- Institute of Neuro-logical Sciences (ICNE), São Paulo-SP, Brazil
- Adjunct Professor of Neurosurgery, Mayo Clinic College of Medicine, Jacksonville, USA
| | - Ossama Al-Mefty
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Guilherme C. Ribas
- Clinical Anatomy Discipline, Department of Surgery, University of São Paulo Medical School (FMUSP), São Paulo, Brazil
- Neurosurgeon Albert Einstein Hospital, São Paulo - SP, Brazil
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Chau AMT, Gagliardi F, Smith A, Pelzer NR, Stewart F, Mortini P, Elbabaa SK, Caputy AJ, Gragnaniello C. The paramedian supracerebellar transtentorial approach to the posterior fusiform gyrus. Acta Neurochir (Wien) 2016; 158:2149-2154. [PMID: 27677522 DOI: 10.1007/s00701-016-2960-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 09/07/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND The posterior fusiform gyrus lies in a surgically challenging region. Several approaches have been described to access this anatomical area. The paramedian supracerebellar transtentorial (SCTT) approach benefits from minimal disruption of normal neurovascular tissue. The aim of this study was to demonstrate its application to access the posterior fusiform gyrus. METHODS Three brains and six cadaveric heads were examined. A stepwise dissection of the SCTT approach to the posterior fusiform gyrus was performed. Local cortical anatomy was studied. The operability score was applied for comparative analysis on surgical anatomy. RESULTS The major posterior landmark used to identify the fusiform gyrus with respect to the medial occipitotemporal gyrus was the collateral sulcus, which commonly bifurcated at its caudal extent. Compared with other surgical approaches addressed to access the region, SCTT demonstrated the best operability in terms of maneuverability arc. Favorable tentorial anatomy is the only limiting factor. CONCLUSIONS The supracerebellar transtentorial approach is able to provide access to the posterior fusiform gyrus via a minimally disruptive, anatomic, microsurgical corridor.
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Affiliation(s)
- Anthony M T Chau
- Macquarie Neurosurgery, Australian School of Advanced Medicine, Macquarie University Hospital, Sydney, Australia
- School of Medicine, University of New England, Armidale, Australia
| | - Filippo Gagliardi
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy.
| | - Adam Smith
- School of Medicine, University of New England, Armidale, Australia
| | | | - Fiona Stewart
- School of Medicine, University of New England, Armidale, Australia
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy
| | - Samer K Elbabaa
- Department of Neurological Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Anthony J Caputy
- Department of Neurosurgery, George Washington University, Washington, DC, USA
| | - Cristian Gragnaniello
- Macquarie Neurosurgery, Australian School of Advanced Medicine, Macquarie University Hospital, Sydney, Australia
- School of Medicine, University of New England, Armidale, Australia
- Department of Neurosurgery, George Washington University, Washington, DC, USA
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Grigoryan YA, Sitnikov AR, Timoshenkov AV, Grigoryan GY. [The paramedian supracerebellar transtentorial approach to the mediobasal temporal region]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2016; 80:48-62. [PMID: 27500774 DOI: 10.17116/neiro201680448-62] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
UNLABELLED The mediobasal temporal region (MTR) is located near the brain stem and surrounded by the eloquent neurovascular structures. The supracerebellar transtentorial approach (STA) is safe access to the posterior MTR structures, however its use for resection of anterior MTR lesions still remains controversial. The article describes the technique and outcome of surgery for different MTR structures using STA. MATERIAL AND METHODS The paramedian STA was used in 18 patients (13 females and 5 males) for 7 years. Ten patients presented with glial MTR tumors, 3 patients with cavernomas, 2 patients with arteriovenous malformations (AVMs), 2 patients with intraventricular meningiomas, and 1 patient with mesial temporal sclerosis. The patient age ranged from 19 to 57 years. In 10 cases, lesions were localized on the left. Epilepsy was the leading symptom in 14 cases. Patients underwent preoperative high-resolution MRI, electroencephalography video monitoring before and after surgery, intraoperative corticography (if necessary), and postoperative CT and MRI. RESULTS Lesions were located in the anterior third of MTR in 5 patients, in the anterior and middle thirds in 2 patients, in the middle third in 5 patients, in the middle and posterior thirds in 2 patients, in the posterior third in 1 patient, in the anterior, middle, and posterior thirds in 1 patient, and in the ventricular triangle area in 2 patients. In all patients with intraventricular tumors, AVMs, and cavernous malformations and in 8 patients with glial MTR tumors, the lesions were totally resected. Two patients with intracerebral tumors underwent subtotal resection. A patient with intractable epilepsy and mesial temporal sclerosis underwent resection of the anterior two-thirds of the hippocampus and parahippocampal gyrus and, partially, amygdala using intraoperative corticography. There was no surgical mortality; 2 patients developed a transient neurological deficit, and 1 patient had a cerebellar hematoma that was successfully removed during surgery. CONCLUSION STA enables resection of lesions localized in all parts of the MTR, without damage to the surrounding nerve and vascular structures.
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Affiliation(s)
- Yu A Grigoryan
- Federal Center of Treatment and Rehabilitation, Moscow, Russia
| | - A R Sitnikov
- Federal Center of Treatment and Rehabilitation, Moscow, Russia
| | - A V Timoshenkov
- Federal Center of Treatment and Rehabilitation, Moscow, Russia
| | - G Yu Grigoryan
- Federal Center of Treatment and Rehabilitation, Moscow, Russia
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Duan H, Hara Y, Goto T, Chiba A, Hongo K. Giant cavernous malformation in the ventrolateral midbrain with extension into the thalamus: a case report of a paramedian supracerebellar transtentorial approach. Acta Neurochir (Wien) 2016; 158:1533-8. [PMID: 27328840 DOI: 10.1007/s00701-016-2870-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 06/02/2016] [Indexed: 11/26/2022]
Abstract
Cavernous malformations (CMs) of the midbrain and thalamus are relatively rare and particularly difficult to be resected given their location in eloquent tissues. Here, we report a case of a 14-year-old boy who experienced repeated and progressive right hemiparesis. Image examinations showed a gradually enlarged CM originated in the left ventrolateral midbrain extending to the left thalamus with repeated hemorrhage. By performing a paramedian supracerebellar transtentorial approach, the CM was totally removed, and the patient recovered without any new neurological deficit. The authors' experience suggests that this approach is eminent in treating giant lesions involving the ventrolateral midbrain and thalamus.
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Affiliation(s)
- Hongzhou Duan
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
- Department of Neurosurgery, Peking University First Hospital, Xicheng District, Beijing, China
| | - Yosuke Hara
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Tetsuya Goto
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.
| | - Akihiro Chiba
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Kazuhiro Hongo
- Department of Neurosurgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
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Konovalov AN, Pitskhelauri DI, Melikyan AG, Shishkina LV, Serova NK, Pronin IN, Eliseeva NM, Shkatova AM, Samborskiy DY, Bykanov AE, Golovteev AL, Grinenko OA, Kopachev DN. [Supracerebellar transtentorial approach to tumors of the posterior portions of the medial temporal region]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2016; 79:38-47. [PMID: 26529621 DOI: 10.17116/neiro201579438-47] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Despite the advances in microsurgery, the choice of the most adequate approach to the posterior part of the medial temporal region (MTR) remains a very controversial issue. The supracerebellar transtentorial approach (STA) is considered as the most preferable one, since it provides the optimal balance between retraction, incision, and resection of the brain tissue. Here, we present our consecutive series of 20 patients who underwent STA surgery. MATERIAL AND METHODS Twenty patients with glial tumors affecting the posterior MTR underwent STA surgery between 2006 and 2014. The mean age of the patients was 20 years. Benign tumors were predominant (18 out of 20 cases). RESULTS Resection of the posterior and middle MTRs was conducted in 16 cases. The anterior MTR was accessed through STA in 1 patient only; in 2 patients, STA was combined with the infraoccipital approach. Cerebellar edema occurred in 4 patients, with hemiparesis persisting in one of the cases for 1 year after surgery. Of 8 patients with drug resistant epilepsy, the Engel class 1 or 2 outcome was achieved in 6 cases within 1 year after surgery. CONCLUSION STA provides an excellent surgical route to the posterior and middle MTR portions; however, the anterior MTR portions cannot be reached safely. The operative risks of STA increase as the surgeon proceeds with resection of the anterior MTR portions. Anterior MTR structures can be removed using a combination of the supracerebellar and infraoccipital transtentorial approaches or two-stage resection.
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Affiliation(s)
| | | | - A G Melikyan
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - N K Serova
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - I N Pronin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - N M Eliseeva
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A M Shkatova
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - A E Bykanov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - O A Grinenko
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - D N Kopachev
- Burdenko Neurosurgical Institute, Moscow, Russia
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Villanueva P, Louis RG, Cutler AR, Wei H, Sale D, Duong HT, Barkhoudarian G, Kelly DF. Endoscopic and Gravity-Assisted Resection of Medial Temporo-occipital Lesions Through a Supracerebellar Transtentorial Approach: Technical Notes With Case Illustrations. Oper Neurosurg (Hagerstown) 2015; 11:475-483. [PMID: 29506159 DOI: 10.1227/neu.0000000000000970] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 06/22/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Traditional approaches to medial temporo-occipital intra-axial brain tumors carry the risk of visual or language deficits related to brain retraction or transgression of deep fiber tracts. To reduce these risks, the microscopic supracerebellar transtentorial approach with the patient in the sitting position has been previously described for lesions in relative proximity to the tentorium. OBJECTIVE We describe this approach performed with endoscopic tumor resection to allow better visualization and a more ergonomic operating position. METHODS Four consecutive patients harboring a medial temporo-occipital lesion are reported. All were operated on while in the sitting position using frameless navigation and a supracerebellar transtentorial approach. Tumor resection was performed by 2 surgeons with endoscopic visualization. RESULTS Pathologies included intraparenchymal metastatic melanoma, cavernous hemangioma, and ganglioglioma, as well as an intraventricular metastatic tumor. The distance from the tentorium to the lesion ranged from 1 to 4 mm. Gross total resection was achieved in 3 of the 4 patients. The patient with a metastatic melanoma had an intentional near-total resection given the tumor encasing a branch of the posterior cerebral artery. The patient with the intraventricular tumor sustained a small but symptomatic infarct of the lateral geniculate region, resulting in a visual field deficit. CONCLUSION This small series suggests that the endoscopic supracerebellar transtentorial approach with the patient in the sitting position can be a safe and effective approach for removing medial temporo-occipital lesions. It allows excellent tumor visualization, eliminates the need for brain retraction, minimizes parenchymal transgression, and improves surgical ergonomics. Significant experience in endoscopy and excellent neuroanesthesia support are recommended before undertaking this approach.
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Affiliation(s)
- Pablo Villanueva
- Department of Neurosurgery, Catholic University of Chile, Santiago, Chile
| | - Robert G Louis
- ONE Brain and Spine Center, Hoag Memorial Hospital Presbyterian, Newport Beach, California
| | | | - Hua Wei
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Danjuma Sale
- Department of Surgery, Neurosurgery Unit, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria
| | - Huy T Duong
- Department of Neurosurgery, Kaiser Medical Center Sacramento, Sacramento, California
| | - Garni Barkhoudarian
- Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California
| | - Daniel F Kelly
- Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California
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Campero A. [Microsurgical anatomy and approaches of mesial temporal cavernomas]. Surg Neurol Int 2015; 6:S530-7. [PMID: 26600986 PMCID: PMC4623614 DOI: 10.4103/2152-7806.167204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 08/16/2015] [Indexed: 11/08/2022] Open
Abstract
Objetivo: Describir la anatomía microquirúrgica y los abordajes a la región temporal mesial (RTM), en relación a cavernomas de dicho sector. Materiales y Método: Cinco cabezas de cadáveres adultos, fijadas en formol e inyectadas con silicona coloreada, fueron estudiadas. Además, desde enero de 2007 a junio de 2014, 7 pacientes con cavernomas localizados en la RTM fueron operados por el autor. Resultados: Anatomia: La RTM fue dividida en 3 sectores: Anterior, medio y posterior. Pacientes: 7 enfermos con cavernomas de la RTM fueron operados por el autor. De acuerdo a la ubicacion en la RTM, 4 cavernomas se ubicaron en el sector anterior, 2 cavernomas se localizaron en el sector medio y 1 cavernoma se ubico en el sector posterior. Para el sector anterior de la RTM se utilizo un abordaje transsilviano-transinsular; para el sector medio de la RTM se utilizo un abordaje transtemporal (lobectomia temporal anterior); y para el sector posterior de la RTM se utilizo un abordaje supracerebeloso-transtentorial. Conclusión: Dividir la RTM en 3 sectores nos permite adecuar el abordaje en función a la localización de la lesión. Así, el sector anterior es bien abordable a través de la fisura silviana; el sector medio a través de una vía transtemporal; y el sector posterior por un abordaje supracerebeloso.
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Affiliation(s)
- Alvaro Campero
- Servicio de Neurocirugía, Hospital Padilla, Tucumán, Argentina
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Ribas EC, Yagmurlu K, Wen HT, Rhoton AL. Microsurgical anatomy of the inferior limiting insular sulcus and the temporal stem. J Neurosurg 2015; 122:1263-73. [DOI: 10.3171/2014.10.jns141194] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The purpose of this study was to describe the location of each white matter pathway in the area between the inferior limiting insular sulcus (ILS) and temporal horn that may be crossed in approaches through the temporal stem to the medial temporal lobe.
METHODS
The fiber tracts in 14 adult cadaveric cerebral hemispheres were examined using the Klingler technique. The fiber dissections were completed in a stepwise manner, identifying each white matter pathway in different planes and describing its position in relation to the anterior end of the ILS.
RESULTS
The short-association fibers from the extreme capsule, which continue toward the operculae, are the most superficial subcortical layer deep to the ILS. The external capsule fibers are found deeper at an intermediate layer and are formed by the uncinate fasciculus, inferior frontooccipital fasciculus, and claustrocortical fibers in a sequential anteroposterior disposition. The anterior commissure forms the next deeper layer, and the optic radiations in the sublenticular part of the internal capsule represent the deepest layer. The uncinate fasciculus is found deep to the anterior third of the ILS, whereas the inferior frontooccipital fasciculus and optic radiations are found superficial and deep, respectively, at the posterior two-thirds of this length.
CONCLUSIONS
The authors' findings suggest that in the transsylvian approach, a 6-mm incision beginning just posterior to the limen insula through the ILS will cross the uncinate fasciculus but not the inferior frontooccipital fasciculus or optic radiations, but that longer incisions carry a risk to language and visual functions.
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Affiliation(s)
- Eduardo Carvalhal Ribas
- 1Department of Neurosurgery, University of Florida, Gainesville, Florida; and
- 2Division of Neurosurgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Kaan Yagmurlu
- 1Department of Neurosurgery, University of Florida, Gainesville, Florida; and
| | - Hung Tzu Wen
- 2Division of Neurosurgery, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Albert L. Rhoton
- 1Department of Neurosurgery, University of Florida, Gainesville, Florida; and
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Nayak NR, Thawani JP, Sanborn MR, Storm PB, Lee JYK. Endoscopic approaches to brainstem cavernous malformations: Case series and review of the literature. Surg Neurol Int 2015; 6:68. [PMID: 25984383 PMCID: PMC4418103 DOI: 10.4103/2152-7806.155807] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 12/21/2014] [Indexed: 11/26/2022] Open
Abstract
Background: Symptomatic cavernous malformations involving the brainstem are frequently difficult to access via traditional methods. Conventional skull-base approaches require significant brain retraction or bone removal to provide an adequate operative corridor. While there has been a trend toward limited employment of the most invasive surgical approaches, recent advances in endoscopic technology may complement existing methods to access these difficult to reach areas. Case Descriptions: Four consecutive patients were treated for symptomatic, hemorrhagic brainstem cavernous malformations via fully endoscopic approaches (endonasal, transclival; retrosigmoid; lateral supracerebellar, infratentorial; endonasal, transclival). Together, these lesions encompassed all three segments of the brainstem. Three of the patients had complete resection of the cavernous malformation, while one patient had stable residual at long-term follow up. Associated developmental venous anomalies were preserved in the two patients where one was identified preoperatively. Three of the four patients maintained stable or improved neurological examinations following surgery, while one patient experienced ipsilateral palsies of cranial nerves VII and VIII. The first transclival approach resulted in a symptomatic cerebrospinal fluid leak requiring re-operation, but the second did not. Although there are challenges associated with endoscopic approaches, relative to our prior microsurgical experience with similar cases, visualization and illumination of the surgical corridors were superior without significant limitations on operative mobility. Conclusion: The endoscope is a promising adjunct to the neurosurgeon's ability to approach difficult to access brainstem cavernous malformations. It allows the surgeon to achieve well-illuminated, panoramic views, and by combining approaches, can provide minimally invasive access to most regions of the brainstem.
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Affiliation(s)
- Nikhil R Nayak
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Silverstein Pavilion 3, Philadelphia, PA 19104
| | - Jayesh P Thawani
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Silverstein Pavilion 3, Philadelphia, PA 19104
| | - Matthew R Sanborn
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Silverstein Pavilion 3, Philadelphia, PA 19104
| | - Phillip B Storm
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Wood Building, Philadelphia, PA 19104
| | - John Y K Lee
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Silverstein Pavilion 3, Philadelphia, PA 19104
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Weil AG, Middleton AL, Niazi TN, Ragheb J, Bhatia S. The supracerebellar-transtentorial approach to posteromedial temporal lesions in children with refractory epilepsy. J Neurosurg Pediatr 2015; 15:45-54. [PMID: 25396700 DOI: 10.3171/2014.10.peds14162] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Operations on tumors of the posteromedial temporal (PMT) region, that is, on those arising from the posterior parahippocampal, fusiform, and lingual gyri, are challenging to perform because of the deep-seated location of these tumors between critical cisternal neurovascular structures and the adjacent temporal and occipital cortexes. Traditional surgical approaches require temporal or occipital transgression, retraction, or venous sacrifice. These approaches may result in unintended complications that should be avoided. To avoid these complications, the supracerebellar-transtentorial (SCTT) approach to this region has been used as an effective alternative treatment in adult patients. The SCTT approach uses a sitting position that offers a direct route to the posterior fusiform and lingual gyri of the temporal lobe. The authors report the feasibility, safety, and efficacy of this approach, using a modified lateral park-bench position in a small cohort of pediatric patients. METHODS The authors carried out a retrospective case review of 5 consecutive patients undergoing a paramedian SCTT approach between 2009 and 2014 at the authors' institution. RESULTS The SCTT approach in the park-bench position was used in 3 boys and 2 girls with a mean age of 7.8 years (range 13 months to 16 years). All patients presented with a seizure disorder related to a tumor in a PMT region involving the parahippocampal and fusiform gyri of the left (n = 3) or right (n = 2) temporal lobe. No procedure-related complications were observed. Gross-total resection and control of seizures were achieved in all cases. Tumor classes and types included 1 Grade II astrocytoma, 1 pleomorphic xanthoastrocytoma, 1 ganglioglioma, and 2 glioneural tumors. None of the tumors had recurred by the mean follow-up of 22 months (range 1-48 months). Outcomes of epileptic seizures were excellent, with seizure symptoms in all 5 patients scoring in Engel Class IA. CONCLUSIONS The SCTT approach represents a viable option when resecting tumors in this region, providing a reasonable working corridor and low morbidity. The authors' experience in a cohort of pediatric patients demonstrates that complete resection of the lesions in this location is feasible and is safe when involving an approach that involves using a park-bench lateral positioning.
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Affiliation(s)
- Alexander G Weil
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Miller School of Medicine, University of Miami, Miami Children's Hospital, Miami, Florida
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Ansari SF, Young RL, Bohnstedt BN, Cohen-Gadol AA. The extended supracerebellar transtentorial approach for resection of medial tentorial meningiomas. Surg Neurol Int 2014; 5:35. [PMID: 24778923 PMCID: PMC3994713 DOI: 10.4103/2152-7806.128918] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 10/24/2013] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The supracerebellar transtentorial (SCTT) approach has been established as a safe corridor to access the posteriomedial basal temporal region. Previous reports have demonstrated the efficacy of this route in the resection of intrinsic tumors and small arteriovenous malformations. Only one report in the English literature has described its use to resect a medial tentorial meningioma. METHODS The authors discuss the relevant surgical anatomy of this approach and its advantages compared with more traditional routes, and illustrate its application to remove medial tentorial meningiomas through two operative cases with accompanying videos. RESULTS In illustrative case one, the patient recovered from surgery with no deficits. All his preoperative symptoms had resolved at 3-month follow-up. At the 4-year follow-up, MRI did not demonstrate any growth of the residual tumor. In case two, gross total resection was achieved and the patient did not suffer any postoperative language or visual deficit. At 2-year follow-up, no tumor recurrence was present. CONCLUSION The SCTT approach has a potential to safely access extra-axial lesions located around the medial tentorial incisura. As demonstrated in these two cases, the approach merits consideration in patients with tentorial meningiomas as an alternative to more widely utilized skull base approaches and subtemporal routes.
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Affiliation(s)
- Shaheryar F Ansari
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ronald L Young
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Bradley N Bohnstedt
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Aaron A Cohen-Gadol
- Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Gonçalves-Ferreira A, Campos AR, Herculano-Carvalho M, Pimentel J, Bentes C, Peralta AR, Morgado C. Amygdalohippocampotomy: surgical technique and clinical results. J Neurosurg 2013; 118:1107-13. [PMID: 23432145 DOI: 10.3171/2013.1.jns12727] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The removal of mesial temporal structures, namely amygdalohippocampectomy, is the most efficient surgical procedure for the treatment of epilepsy. However, disconnection of the epileptogenic zones, as in temporal lobotomy or, for different purposes, hemispherotomy, have shown equivalent results with less morbidity. Thus, authors of the present study began performing selective amygdalohippocampotomy in cases of refractory mesial temporal lobe epilepsy (TLE) to treat mesial temporal lobe sclerosis (MTLS). METHOD The authors conducted a retrospective analysis of all cases of amygdalohippocampotomy collected in a database between November 2007 and March 2011. RESULTS Since 2007, 21 patients (14 males and 7 females), ages 20-58 years (mean 41 years), all with TLE due to MTLS, were treated with selective ablation of the lateral amygdala plus perihippocampal disconnection (anterior one-half to two-thirds in dominant hemisphere), the left side in 11 cases and the right in 10. In 20 patients the follow-up was 2 or more years (range 24-44 months, average 32 months). Clinical outcome for epilepsy 2 years after surgery (20 patients) was good/very good in 19 patients (95%) with an Engel Class I (15 patients [75%]) or II outcome (4 patients [20%]) and bad in 1 patient (5%) with an Engel Class IV outcome (extratemporal focus and later reoperation). Surgical morbidity included hemiparesis (capsular hypertensive hemorrhage 24 hours after surgery, 1 patient), verbal memory worsening (2 patients), and quadrantanopia (permanent in 2 patients, transient in 1). Late psychiatric depression developed in 3 cases. Operative time was reduced by about 30 minutes (15%) on average with this technique. CONCLUSIONS Amygdalohippocampotomy is as effective as amygdalohippocampectomy to treat MTLS and is a potentially safer, time-saving procedure.
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