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Weiß S, Thomale UW, Schulz M, Kandels D, Schuhmann MU, El Damaty A, Krauss J, Driever PH, Witt O, Bison B, Pietsch T, Gnekow A, Simon M. Neurosurgical morbidity in pediatric supratentorial midline low-grade glioma: Results from the German LGG studies. Int J Cancer 2023; 153:1487-1500. [PMID: 37260252 DOI: 10.1002/ijc.34615] [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: 01/28/2023] [Revised: 03/24/2023] [Accepted: 04/05/2023] [Indexed: 06/02/2023]
Abstract
Surgical resection is a mainstay of treatment for pediatric low-grade glioma (LGG) within all current therapy algorithms, yet associated morbidity is scarcely reported. As supratentorial midline (SML) interventions are particularly challenging, we investigated the frequency of neurosurgical complications/new impairments aiming to identify their risk factors. Records were retrospectively analyzed from 318 patients with SML-LGG from successive German multicenter LGG studies, undergoing surgery between May 1998 and June 2020. Exactly 537 operations (230 resections, 167 biopsies, 140 nontumor procedures) were performed in 318 patients (54% male, median age: 7.6 years at diagnosis, 9.5 years at operation, 11% NF1, 42.5% optic pathway glioma). Surgical mortality rate was 0.93%. Applying the Drake classification, postoperative surgical morbidity was observed following 254/537 (47.3%) and medical morbidity following 97/537 (18.1%) patients with a 40.1% 30-day persistence rate for newly developed neurological deficits (65/162). Neuroendocrine impairment affected 53/318 patients (16.7%), visual deterioration 34/318 (10.7%). Postsurgical morbidity was associated with patient age <3 years at operation, tumor volume ≥80 cm3 , presence of hydrocephalus, complete resection, surgery in centers with less than median reported tumor-related procedures and during the earlier study period between 1998 and 2006, while the neurosurgical approach, tumor location, NF1 status or previous nonsurgical treatment were not. Neurosurgery-associated morbidity was frequent in pediatric patients with SML-LGG undergoing surgery in the German LGG-studies. We identified patient- and institution-associated factors that may increase the risk for complications. We advocate that local multidisciplinary teams consider the planned extent of resection and surgical skills.
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Affiliation(s)
- Sarah Weiß
- Department of Pediatric Oncology and Hematology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ulrich-Wilhelm Thomale
- Department of Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Schulz
- Department of Pediatric Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Daniela Kandels
- Swabian Children's Cancer Center, Faculty of Medicine, University Augsburg, Augsburg, Germany
| | - Martin U Schuhmann
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tuebingen, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Ahmed El Damaty
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Juergen Krauss
- Department of Pediatric Neurosurgery, University Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Pablo Hernáiz Driever
- Department of Pediatric Oncology and Hematology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Olaf Witt
- Hopp Children's Cancer Center Heidelberg (KiTZ), Clinical Cooperation Unit Pediatric Oncology, German Cancer Research Center (DKFZ), Heidelberg University Hospital, National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Brigitte Bison
- Diagnostic and Interventional Neuroradiology, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Torsten Pietsch
- Department of Neuropathology and DGNN Brain Tumor Reference Center, University of Bonn Medical Center, Bonn, Germany
| | - Astrid Gnekow
- Swabian Children's Cancer Center, Faculty of Medicine, University Augsburg, Augsburg, Germany
| | - Michèle Simon
- Department of Pediatric Oncology and Hematology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Kadri PAS, Ibn Essayed W, Al-Mefty O. The Resection of a Thalamic Pilocytic Astrocytoma Through the Transchoroidal Fissure, Transcallosal Approach: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E346-E347. [PMID: 33855454 DOI: 10.1093/ons/opab015] [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: 09/28/2020] [Accepted: 12/11/2020] [Indexed: 11/14/2022] Open
Abstract
Surgical resection is the primary treatment of pilocytic astrocytomas and total removal can be curative. However, these lesions occur in critical areas, such as the thalamus, being surrounded by critical life neurovascular structures, which imposes a surgical challenge.1-5 Exhaustive acquisition and meticulous interpretation of preoperative radiological exams; reliable surgical orientation based on profound microneurosurgical anatomic knowledge and judicious discernment of the neuroanatomic distortions on the surface and deep-seated structures inflicted by the neuropathological entity; embracing and comprehensive application of the vast scope of available intraoperative guidance imaging and neurophysiological monitoring; in alliance with the mastered carefully microsurgical technique supported by endoscopic visualization are the keystones to the pursed duet "cure with quality of life" in the treatment of these lesions. We present the case of a 17-yr-old young lady with a progressive motor deficit in her right hemibody for over 2 yr. Her radiological investigation demonstrated a left thalamic lesion displacing the projection fibers (corticospinal tract) within the internal capsule laterally. The patient consented to the surgical procedure. The surgical strategy, intraoperative findings, and microsurgical and endoscopic technique, as well as the postoperative radiological and clinical evaluation are presented. The patient gave her informed consent for the publication of the case.
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Affiliation(s)
- Paulo A S Kadri
- Department of Neurosurgery, Federal University of Mato Grosso do Sul, Campo Grande, Brazil
| | - Walid Ibn Essayed
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ossama Al-Mefty
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Pruthi N, Kadri PAS, Türe U. Fiber Microdissection Technique for Demonstrating the Deep Cerebellar Nuclei and Cerebellar Peduncles. Oper Neurosurg (Hagerstown) 2021; 20:E118-E125. [PMID: 33047123 DOI: 10.1093/ons/opaa318] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 08/02/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The cerebellum is one of the most primitive and complex parts of the human brain. The fiber microdissection technique can be extremely useful for neurosurgeons to understand the topographical organization of the cerebellum's important contents, such as the deep cerebellar nuclei and the cerebellar peduncles, and their relationship with the brain stem. OBJECTIVE To dissect the deep cerebellar nuclei and the cerebellar peduncles using the fiber microdissection technique. METHODS Under the operating microscope, 5 previously frozen, formalin-fixed human cerebellums and brain stems were dissected from the superior surface, and 5 were dissected from the inferior surface. Each stage of the process is described. The primary dissection tools were handmade, thin, wooden spatulas with tips of various sizes, toothpicks, and a fine regulated suction. RESULTS In 15 simplified dissection steps (6 for the superior surface and 9 for the inferior surface), the deep cerebellar nuclei (dentate, interpositus, and fastigial) and the cerebellar peduncles (inferior, middle, and superior) are delineated. Their anatomical relationships with each other and other neighboring structures are demonstrated. CONCLUSION The anatomy of the deep cerebellar nuclei and the cerebellar peduncles are clearly defined and understood through the use of the fiber microdissection technique. These stepwise dissections will guide the neurosurgeon in acquiring a topographical understanding of these complex and deep structures of the cerebellum. This knowledge, along with radiological information, can help in planning the most appropriate surgical strategy for various lesions of the cerebellum.
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Affiliation(s)
- Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India.,Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey
| | - Paulo A S Kadri
- Division of Neurosurgery, School of Medicine, Federal University of Mato Grosso do Sul, Campo Grande, Brazil
| | - Uğur Türe
- Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey
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Postmortem Dissections of the Papez Circuit and Nonmotor Targets for Functional Neurosurgery. World Neurosurg 2020; 144:e866-e875. [DOI: 10.1016/j.wneu.2020.09.088] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/16/2020] [Accepted: 09/16/2020] [Indexed: 12/11/2022]
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Barrenechea IJ, Márquez L, Miralles S, Baldoncini M, Peralta S. An alternative path to atrial lesions through a contralateral interhemispheric transfalcine transcingular infra-precuneus approach: A case report. Surg Neurol Int 2020; 11:407. [PMID: 33365170 PMCID: PMC7749951 DOI: 10.25259/sni_608_2020] [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: 09/05/2020] [Accepted: 11/07/2020] [Indexed: 12/02/2022] Open
Abstract
Background: The surgical management of lesions located in the trigone of the lateral ventricle remains a neurosurgical challenge. Previously described approaches to the atrium include the transtemporal, parietal transcortical, parietal trans intraparietal sulcus, occipital transcingulate, posterior transcallosal, and transfalcine transprecuneus. However, reaching this area specifically through the cingulate cortex below the subparietal sulcus has not been described thus far. Case Description: We present here the removal of a left atrial meningioma through a right parietal “contralateral interhemispheric transfalcine transcingular infra-precuneus” approach and compare it with previously described midline approaches to the atrium. To accomplish this, a right parietal craniotomy was performed. After the left subprecuneus cingulate cortex was exposed through a window in the falx, a limited corticotomy was performed, which allowed the tumor to be reached after deepening the bipolar dissection by 8 mm. Postoperative magnetic resonance imaging showed complete resection of the lesion sparing the corpus callosum, forceps major, and sagittal stratum. Although this approach disrupts the posterior cingulate fasciculus, no deficits have been described so far after unilaterally disrupting the posterior cingulate cortex or the posterior part of the cingulate fasciculus. In fact, a thorough postoperative cognitive examination did not show any deficits. Conclusion: The “contralateral interhemispheric transfalcine transcingular infra-precuneus” approach combines the advantages of several previously described approaches. Since it conserves the major white matter tracts that surround the atrium and has a shorter attack angle than the contralateral transfalcine transprecuneus approach, we believe that it could be a potentially new alternative path to reach atrial lesions.
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Affiliation(s)
| | - Luis Márquez
- Department of Neurosurgery Hospital Privado de Rosario, Rosario, Santa Fe, Argentina
| | - Sabrina Miralles
- Department of Neuroradiology, Hospital Privado de Rosario, Rosario, Santa Fe, Argentina
| | - Matias Baldoncini
- Department of Surgical Neuroanatomy Laboratory, Department of Anatomy, University of Buenos Aires, Argentina,
| | - Silvina Peralta
- Department of Neuropsychology, Hospital Privado de Rosario, Rosario, Santa Fe, Argentina
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Capilla-Guasch P, Quilis-Quesada V, Regin-Neto M, Holanda VM, González-Darder JM, de Oliveira E. White Matter Relationships Examined by Transillumination Technique Using a Lateral Transcortical Parietal Approach to the Atrium: Three-Dimensional Images and Surgical Considerations. World Neurosurg 2019; 132:e783-e794. [PMID: 31415888 DOI: 10.1016/j.wneu.2019.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/02/2019] [Accepted: 08/03/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Numerous lesions are found in the ventricular atrium (VA). Access is gained through many white matter tracts with great relevance and specific neurologic functions. It is important to understand the configuration of the most relevant structures surrounding this zone and, thus, select the safest entry zone on the lateral cerebral surface. OBJECTIVE We studied the white matter layers traversed in the lateral transcortical parietal approach through the intraparietal sulcus (IPS), adding a transillumination technique. With this knowledge, we selected the safest highway to improve this particular approach. METHODS An in-depth study of the white matter tracts was performed on 24 cerebral hemispheres (12 human whole brains). The Klingler technique and microsurgical dissection techniques were used under ×6 to ×40 magnification. The transillumination technique (torch illuminating the ventricular cavity) was used to expose the layers surrounding the VA and, thus, guide the dissection. RESULTS Taking the IPS on the cerebral surface as a reference, we identified the following white matter layers ordered from the surface to the ependyma: U fibers, superior longitudinal fascicle, arcuate fascicle, vertical occipital fascicle, sagittal stratum with the optic radiations, and tapetum fibers. The transillumination technique allowed for the easier identification of the white matter deep periventricular layers. CONCLUSIONS Knowledge of the main fascicles in the path and neighborhood of the VA allowed us to understand how certain neurologic functions can be affected by lesions at this level and to select the most appropriate way to avoid damaging relevant fascicles.
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Affiliation(s)
- Pau Capilla-Guasch
- Department of Neurosurgery, Hospital Clínico Universitario de Valencia, Valencia, Spain; Department of Anatomy and Human Embriology, Microneurosurgery Laboratory, University of Valencia, Valencia, Spain.
| | - Vicent Quilis-Quesada
- Department of Neurosurgery, Hospital Clínico Universitario de Valencia, Valencia, Spain; Department of Anatomy and Human Embriology, Microneurosurgery Laboratory, University of Valencia, Valencia, Spain; Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | - Mateus Regin-Neto
- Institute of Neurological Sciences (ICNE), São Paulo, Brazil; Microneurosurgery Laboratory, Hospital Beneficieência Portuguesa, São Paulo, Brazil
| | - Vanessa M Holanda
- Institute of Neurological Sciences (ICNE), São Paulo, Brazil; Microneurosurgery Laboratory, Hospital Beneficieência Portuguesa, São Paulo, Brazil
| | - José M González-Darder
- Department of Neurosurgery, Hospital Clínico Universitario de Valencia, Valencia, Spain; Department of Anatomy and Human Embriology, Microneurosurgery Laboratory, University of Valencia, Valencia, Spain
| | - Evandro de Oliveira
- Institute of Neurological Sciences (ICNE), São Paulo, Brazil; Microneurosurgery Laboratory, Hospital Beneficieência Portuguesa, São Paulo, Brazil
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Baldoncini M, Campero A, Pérez Cruz JC, Recalde R, Parraga R, Sanchez Gonzalez FJ, Fortte M, López PG. Microsurgical Anatomy and Approaches to the Cerebral Central Core. World Neurosurg 2019; 129:e23-e34. [PMID: 31103755 DOI: 10.1016/j.wneu.2019.04.139] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/15/2019] [Accepted: 04/16/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Through a cadaveric study, we divided the cerebral central core (CCC) into different areas and have proposed a corresponding neurosurgical approach for each sector. As a secondary objective, we analyzed the cortical and subcortical microsurgical anatomy of the CCC. The CCC includes the insula, extreme capsule, claustrum, external capsule, lenticular nucleus, internal capsule, caudate nucleus, and thalamus. METHODS Twelve adult human brain hemispheres and one cadaveric head specimen were dissected and studied at the Laboratory of Neuroanatomic Microsurgical of the University of Buenos Aires. Nine cases of CCC neurosurgical pathologies were included in the present study and analyzed. Digital drawings were created of the approaches proposed for each sector of the CCC showing the most relevant surgical details. Photographs of each dissection and measurements obtained were taken. RESULTS We divided the CCC into a medial, intermediate, and lateral sector, with specific subdivisions for the lateral and medial sectors. The lateral projection of the foramen of Monro was found deep to the third short gyri of the insula with the following distances: anterior insular limen margin, 23.95 mm; posterior insular limen margin, 22.92 mm; superior limiting sulcus, 14.99 mm, and inferior limiting sulcus, 13.76 mm. We have proposed the following approaches: an ipsilateral transcallosal approach, a contralateral transcallosal approach, a choroidal transfissure approach, a trans-splenial approach, transparietal access entering the intraparietal sulcus, and trans-sylvian approach. The preoperative imaging studies should be analyzed using our method to select the most accurate and safe approach. CONCLUSIONS We have provided a description of the limits and anatomy of the CCC using brain dissection, an analysis of operated cases, and useful measurements for the neurosurgeon.
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Affiliation(s)
- Matias Baldoncini
- Department of Neurological Surgery, San Fernando Hospital, Buenos Aires, Argentina; Laboratory of Neuroanatomic Microsurgical, II Division of Anatomy, Medicine School, University of Buenos Aires, Buenos Aires, Argentina.
| | - Alvaro Campero
- Laboratory of Neuroanatomic Microsurgical, II Division of Anatomy, Medicine School, University of Buenos Aires, Buenos Aires, Argentina; Department of Neurological Surgery, Padilla Hospital, Tucumán, Argentina
| | - Julio César Pérez Cruz
- Anatomy Academy, Higher School of Medicine, Instituto Politécnico Nacional Neurosciences, Faculty of Medicine, Autonomous National University of Mexico, Mexico City, Mexico
| | - Rodolfo Recalde
- Skull Base Section and Neuroanatomic Laboratory, Neurosurgical Division, Clinical Hospital, University of Buenos Aires, Buenos Aires, Argentina
| | - Richard Parraga
- Department of Neurological Surgery, Hospital Univalle, Cochabamba-Cercado, Bolivia; Institute of Neurological Sciences, São Paulo, Brazil
| | - Federico J Sanchez Gonzalez
- Epilespy Surgery Section, Neurosurgical Division, Clinical Hospital, University of Buenos Aires, Buenos Aires, Argentina; Neurosurgical Division, Clinic of Cuyo, Mendoza, Argentina
| | - Martin Fortte
- Division Neurosurgery, Interzonal Specialized Children's Hospital, Mar del Plata, Argentina; Belgrano Clinic and 25 de Mayo Clinic, Mar del Plata, Argentina
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Rodríguez-Mena R, Piquer-Belloch J, Llácer-Ortega JL, Riesgo-Suárez P, Rovira-Lillo V. 3D microsurgical anatomy of the cortico-spinal tract and lemniscal pathway based on fiber microdissection and demonstration with tractography. Neurocirugia (Astur) 2018; 29:275-295. [PMID: 30153974 DOI: 10.1016/j.neucir.2018.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/06/2018] [Accepted: 06/03/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To demonstrate tridimensionally the anatomy of the cortico-spinal tract and the medial lemniscus, based on fiber microdissection and diffusion tensor tractography (DTT). MATERIAL AND METHODS Ten brain hemispheres and brain-stem human specimens were dissected and studied under the operating microscope with microsurgical instruments by applying the fiber microdissection technique. Brain magnetic resonance imaging was obtained from 15 healthy subjects using diffusion-weighted images, in order to reproduce the cortico-spinal tract and the lemniscal pathway on DTT images. RESULTS The main bundles of the cortico-spinal tract and medial lemniscus were demonstrated and delineated throughout most of their trajectories, noticing their gross anatomical relation to one another and with other white matter tracts and gray matter nuclei the surround them, specially in the brain-stem; together with their corresponding representation on DTT images. CONCLUSIONS Using the fiber microdissection technique we were able to distinguish the disposition, architecture and general topography of the cortico-spinal tract and medial lemniscus. This knowledge has provided a unique and profound anatomical perspective, supporting the correct representation and interpretation of DTT images. This information should be incorporated in the clinical scenario in order to assist surgeons in the detailed and critic analysis of lesions located inside the brain-stem, and therefore, improve the surgical indications and planning, including the preoperative selection of optimal surgical strategies and possible corridors to enter the brainstem, to achieve safer and more precise microsurgical technique.
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Affiliation(s)
- Ruben Rodríguez-Mena
- Cátedra de Neurociencias - Fundación NISA, CEU Hospital Universitario de la Ribera, Alzira, Valencia, España.
| | - José Piquer-Belloch
- Cátedra de Neurociencias - Fundación NISA, CEU Hospital Universitario de la Ribera, Alzira, Valencia, España
| | - José Luis Llácer-Ortega
- Cátedra de Neurociencias - Fundación NISA, CEU Hospital Universitario de la Ribera, Alzira, Valencia, España
| | - Pedro Riesgo-Suárez
- Cátedra de Neurociencias - Fundación NISA, CEU Hospital Universitario de la Ribera, Alzira, Valencia, España
| | - Vicente Rovira-Lillo
- Cátedra de Neurociencias - Fundación NISA, CEU Hospital Universitario de la Ribera, Alzira, Valencia, España
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Bozkurt B, Yağmurlu K, Belykh E, Tayebi Meybodi A, Staren MS, Aklinski JL, Preul MC, Grande AW, Nakaji P, Lawton MT. Quantitative Anatomic Analysis of the Transcallosal-Transchoroidal Approach and the Transcallosal-Subchoroidal Approach to the Floor of the Third Ventricle: An Anatomic Study. World Neurosurg 2018; 118:219-229. [PMID: 30010067 DOI: 10.1016/j.wneu.2018.05.126] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare transcallosal-transchoroidal and transcallosal-subchoroidal approaches to the ipsilateral and contralateral edges of the floor of the third ventricle using quantitative analyses. METHODS Five formalin-fixed cadaveric human heads (10 sides) were examined under the operating microscope. Quantitative measurements (area of surgical freedom and angle of attack) were obtained using 3-T magnetic resonance imaging and a StealthStation image guidance system. The limits of the surgical approaches were shown by touching a probe to 6 designated points on the floor of the third ventricle. RESULTS The transchoroidal approach provided greater surgical freedom than the subchoroidal approach to access ipsilateral and contralateral middle landmarks at the edges of the floor of the third ventricle in both longitudinal and horizontal planes (P ≤ 0.03). No significant difference between the 2 approaches was found in accessing the anterior and posterior landmarks of the third ventricle in each plane. The surgical freedom to the contralateral anterior, middle, and posterior landmarks was greater than to the ipsilateral landmarks in both the transchoroidal and subchoroidal approaches. CONCLUSIONS The transcallosal-transchoroidal approach, compared with the transcallosal-subchoroidal approach, may provide better exposure and require less retraction for removal of ipsilateral or contralateral lesions located in the midbrain or hypothalamus and situated near the floor of the third ventricle. The contralateral transcallosal approach with either the transchoroidal or subchoroidal approach may provide good surgical freedom for removal of lesions located near the floor of the third ventricle, such as lesions in the midbrain.
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Affiliation(s)
- Baran Bozkurt
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kaan Yağmurlu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Evgenii Belykh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael S Staren
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joseph L Aklinski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Mark C Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew W Grande
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Peter Nakaji
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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De Benedictis A, Nocerino E, Menna F, Remondino F, Barbareschi M, Rozzanigo U, Corsini F, Olivetti E, Marras CE, Chioffi F, Avesani P, Sarubbo S. Photogrammetry of the Human Brain: A Novel Method for Three-Dimensional Quantitative Exploration of the Structural Connectivity in Neurosurgery and Neurosciences. World Neurosurg 2018; 115:e279-e291. [PMID: 29660551 DOI: 10.1016/j.wneu.2018.04.036] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 04/05/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND Anatomic awareness of the structural connectivity of the brain is mandatory for neurosurgeons, to select the most effective approaches for brain resections. Although standard microdissection is a validated technique to investigate the different white matter (WM) pathways and to verify the results of tractography, the possibility of interactive exploration of the specimens and reliable acquisition of quantitative information has not been described. Photogrammetry is a well-established technique allowing an accurate metrology on highly defined three-dimensional (3D) models. The aim of this work is to propose the application of the photogrammetric technique for supporting the 3D exploration and the quantitative analysis on the cerebral WM connectivity. METHODS The main perisylvian pathways, including the superior longitudinal fascicle and the arcuate fascicle were exposed using the Klingler technique. The photogrammetric acquisition followed each dissection step. The point clouds were registered to a reference magnetic resonance image of the specimen. All the acquisitions were coregistered into an open-source model. RESULTS We analyzed 5 steps, including the cortical surface, the short intergyral fibers, the indirect posterior and anterior superior longitudinal fascicle, and the arcuate fascicle. The coregistration between the magnetic resonance imaging mesh and the point clouds models was highly accurate. Multiple measures of distances between specific cortical landmarks and WM tracts were collected on the photogrammetric model. CONCLUSIONS Photogrammetry allows an accurate 3D reproduction of WM anatomy and the acquisition of unlimited quantitative data directly on the real specimen during the postdissection analysis. These results open many new promising neuroscientific and educational perspectives and also optimize the quality of neurosurgical treatments.
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Affiliation(s)
- Alessandro De Benedictis
- Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Roma, Italy.
| | - Erica Nocerino
- Theoretical Physics ETH Zürich, Zurich, Switzerland; LSIS Laboratory-Laboratoire des Sciences de l'Information et des Systèmes, I&M Team, Images & Models AMU, Aix-Marseille Université POLYTECH, Marseille, France
| | - Fabio Menna
- 3D Optical Metrology (3DOM) Unit, Bruno Kessler Foundation (FBK), Trento, Italy
| | - Fabio Remondino
- 3D Optical Metrology (3DOM) Unit, Bruno Kessler Foundation (FBK), Trento, Italy
| | | | - Umberto Rozzanigo
- Department of Radiology, Neuroradiology Unit, "S. Chiara" Hospital, Trento APSS, Italy
| | - Francesco Corsini
- Division of Neurosurgery, Structural and Functional Connectivity (SFC) Lab Project, "S. Chiara" Hospital, Trento APSS, Italy
| | - Emanuele Olivetti
- Neuroinformatics Laboratory (NILab), Bruno Kessler Foundation, Trento, Italy; Center for Mind/Brain Science (CIMeC), University of Trento, Mattarello (TN), Italy
| | - Carlo Efisio Marras
- Neurosurgery Unit, Department of Neuroscience and Neurorehabilitation, Bambino Gesù Children's Hospital, IRCCS, Roma, Italy
| | - Franco Chioffi
- Division of Neurosurgery, Structural and Functional Connectivity (SFC) Lab Project, "S. Chiara" Hospital, Trento APSS, Italy
| | - Paolo Avesani
- Neuroinformatics Laboratory (NILab), Bruno Kessler Foundation, Trento, Italy; Center for Mind/Brain Science (CIMeC), University of Trento, Mattarello (TN), Italy
| | - Silvio Sarubbo
- Division of Neurosurgery, Structural and Functional Connectivity (SFC) Lab Project, "S. Chiara" Hospital, Trento APSS, Italy
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Pascalau R, Popa Stănilă R, Sfrângeu S, Szabo B. Anatomy of the Limbic White Matter Tracts as Revealed by Fiber Dissection and Tractography. World Neurosurg 2018; 113:e672-e689. [PMID: 29501514 DOI: 10.1016/j.wneu.2018.02.121] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 02/19/2018] [Accepted: 02/20/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND The limbic tracts are involved in crucial cerebral functions such as memory, emotion, and behavior. The complex architecture of the limbic circuit makes it harder to approach compared with other white matter networks. Our study aims to describe the 3-dimensional anatomy of the limbic white matter by the use of 2 complementary study methods, namely ex vivo fiber dissection and in vivo magnetic resonance imaging-based tractography. METHODS Three fiber dissection protocols were performed using blunt wooden instruments and a surgical microscope on formalin-fixed brains prepared according to the Klingler method. Diffusion tensor imaging acquisitions were done with a 3-Tesla magnetic resonance scanner on patients with head and neck pathology that did not involve the brain. Fiber tracking was performed with manually selected regions of interest. RESULTS Cingulum, fornix, the anterior thalamic peduncle, the accumbofrontal bundle, medial forebrain bundle, the uncinate fasciculus, the mammillothalamic tract, ansa peduncularis, and stria terminalis were dissected and fiber tracked. For each tract, location, configuration, segmentation, dimensions, dissection and tractography particularities, anatomical relations, and terminations are described. The limbic white matter tracts were systematized as 2 concentric rings around the thalamus. The inner ring is formed by fornix, mammillothalamic tract, ansa peduncularis, stria terminalis, accumbofrontal fasciculus, and medial forebrain bundle and anterior thalamic peduncle, and the outer ring is formed by the cingulum and uncinate fasciculus. CONCLUSIONS This paper proposes a fiber-tracking protocol for the limbic tracts inspired and validated by fiber dissection findings that can be used routinely in the clinical practice.
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Affiliation(s)
- Raluca Pascalau
- Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Roxana Popa Stănilă
- Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania; IMOGEN Research Center, Emergency County Hospital, Cluj-Napoca, Romania
| | - Silviu Sfrângeu
- Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania; IMOGEN Research Center, Emergency County Hospital, Cluj-Napoca, Romania
| | - Bianca Szabo
- Department of Anatomy and Embryology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania; Department of Ophthalmology, Emergency County Hospital, Cluj-Napoca, Romania
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Mammillothalamic and Mammillotegmental Tracts as New Targets for Dementia and Epilepsy Treatment. World Neurosurg 2017; 110:133-144. [PMID: 29129763 DOI: 10.1016/j.wneu.2017.10.168] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/29/2017] [Accepted: 10/31/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND Recently, neuromodulation through deep brain stimulation (DBS) has appeared as a new surgical procedure in the treatment of some types of dementia and epilepsy. The mammillothalamic and mammillotegmental tracts are involved among the new targets. To our knowledge, a review article focused specifically on these mammillary body efferents is lacking in the medical literature. Their contribution to memory is, regrettably, often overlooked. METHODS A review of the relevant literature was conducted. RESULTS There is evidence that mammillary bodies can contribute to memory independently from hippocampal formation, but the mechanism is not yet known. Recent studies in animals have provided evidence for the specific roles of these mammillary body efferents in regulating memory independently. In animal studies, it has been shown that the disruption of the mammillothalamic tract inhibits seizures and that electrical stimulation of the mammillary body or mammillothalamic tract raises the seizure threshold. In humans, DBS targeting the mammillary body through the mammillothalamic tract or the stimulation of the anterior thalamic nucleus, especially in the areas closely related to the mammillothalamic tract, has been found effective in patients with medically refractory epilepsy. Nonetheless, little knowledge exists on the functional anatomy of the mammillary body efferents, and their role in the exact mechanism of epileptogenic activity and in the memory function of the human brain. CONCLUSIONS A comprehensive knowledge of the white matter anatomy of the mammillothalamic and mammillotegmental tracts is crucial since they have emerged as new DBS targets in the treatment of various disorders including dementia and epilepsy.
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Silva SM, Cunha-Cabral D, Andrade JP. Neurosurgical relevance of the dissection of the diencephalic white matter tracts using the Klingler technique. Clin Neurol Neurosurg 2017; 156:35-40. [DOI: 10.1016/j.clineuro.2017.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 02/27/2017] [Accepted: 03/01/2017] [Indexed: 01/08/2023]
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14
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Koutsarnakis C, Liakos F, Kalyvas AV, Komaitis S, Stranjalis G. Letter to the Editor: White matter fiber tract architecture and ventricular surgery. J Neurosurg 2017; 126:1368-1371. [DOI: 10.3171/2016.9.jns162239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Christos Koutsarnakis
- 1Western General Hospital, Edinburgh, United Kingdom
- 2Athens Microneurosurgery Laboratory, University of Athens, Athens, Greece; and
| | - Faidon Liakos
- 2Athens Microneurosurgery Laboratory, University of Athens, Athens, Greece; and
- 3Evangelismos Hospital, Athens, Greece
| | - Aristotelis V. Kalyvas
- 2Athens Microneurosurgery Laboratory, University of Athens, Athens, Greece; and
- 3Evangelismos Hospital, Athens, Greece
| | - Spyros Komaitis
- 2Athens Microneurosurgery Laboratory, University of Athens, Athens, Greece; and
- 3Evangelismos Hospital, Athens, Greece
| | - George Stranjalis
- 2Athens Microneurosurgery Laboratory, University of Athens, Athens, Greece; and
- 3Evangelismos Hospital, Athens, Greece
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Rodríguez-Mena R, Piquer-Belloch J, Llácer-Ortega JL, Riesgo-Suárez P, Rovira-Lillo V. [3D anatomy of cerebellar peduncles based on fibre microdissection and a demonstration with tractography]. Neurocirugia (Astur) 2016; 28:111-123. [PMID: 27986388 DOI: 10.1016/j.neucir.2016.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/02/2016] [Accepted: 10/30/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To perform an anatomical and radiological study, using fibre microdissection and diffusion tensor tractography (DTT), to demonstrate the three-dimensionality of the superior, middle and inferior cerebellar peduncles. MATERIAL AND METHODS A total of 15 brain-stem, 15 cerebellar hemispheres, and 5 brain hemispheres were dissected in the laboratory under the operating microscope with microsurgical instruments between July 2014 and July 2015. Brain magnetic resonance imaging was obtained from 15 healthy subjects between July and December of 2015, using diffusion-weighted images, in order to reproduce the cerebellar peduncles on DTT. RESULTS The main bundles of the cerebellar peduncles were demonstrated and delineated along most of their trajectory in the cerebellum and brain-stem, noticing their overall anatomical relationship to one another and with other white matter tracts and the grey matter nuclei the surround them, with their corresponding representations on DTT. CONCLUSIONS The arrangement, architecture, and general topography of the cerebellar peduncles were able to be distinguished using the fibre microdissection technique. This knowledge has given a unique and profound anatomical perspective, supporting the correct representation and interpretation of DTT images. This information should be incorporated in the clinical scenario in order to assist surgeons in the detailed and critical analysis of lesions that may be located near these main bundles in the cerebellum and/or brain-stem, and therefore, improve the surgical planning and achieve a safer and more precise microsurgical technique.
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Affiliation(s)
- Ruben Rodríguez-Mena
- Hospital Universitario de la Ribera, Alzira, Valencia, España; Cátedra de Neurociencias - Fundación NISA-CEU, Valencia, España.
| | - José Piquer-Belloch
- Hospital Universitario de la Ribera, Alzira, Valencia, España; Cátedra de Neurociencias - Fundación NISA-CEU, Valencia, España
| | - José Luis Llácer-Ortega
- Hospital Universitario de la Ribera, Alzira, Valencia, España; Cátedra de Neurociencias - Fundación NISA-CEU, Valencia, España
| | - Pedro Riesgo-Suárez
- Hospital Universitario de la Ribera, Alzira, Valencia, España; Cátedra de Neurociencias - Fundación NISA-CEU, Valencia, España
| | - Vicente Rovira-Lillo
- Hospital Universitario de la Ribera, Alzira, Valencia, España; Cátedra de Neurociencias - Fundación NISA-CEU, Valencia, España
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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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Rodríguez-Mena R, Türe U. The Medial and Lateral Lemnisci: Anatomically Adjoined But Functionally Distinct Fiber Tracts. World Neurosurg 2016; 99:241-250. [PMID: 27890749 DOI: 10.1016/j.wneu.2016.11.095] [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: 09/17/2016] [Revised: 11/14/2016] [Accepted: 11/15/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The dense and complex distribution of neural structures in the brainstem makes it challenging to understand their real configuration. We used the fiber microdissection technique to show the course of the medial and lateral lemnisci within the brainstem. Although these structures seem anatomically alike, they are functionally distinct. METHODS Fifteen human brainstems and 8 brain hemispheres (formalin-fixed and previously frozen) were dissected and studied under the operating microscope by applying the fiber microdissection technique. RESULTS We delineated and described the medial and lateral lemnisci, noting their gross elaborate arrangement. These structures are intimately compact and closely related to one another in their common trajectory through the tegmenta of the pons and midbrain. However, we were not able to identify the exact origin and termination of their fibers or the accurate delimitation between the medial lemniscus, spinothalamic tract, and lateral lemniscus along their course in the brainstem. CONCLUSIONS Using the fiber microdissection technique, we were able to define a general perspective of the topography and architecture of the medial and lateral lemnisci in the brainstem. This perspective should be incorporated into interpretations of magnetic resonance imaging techniques, recognizing both their benefits and limitations. It should also be applied to surgical planning and strategies to achieve a safer and more precise microsurgical procedure.
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Affiliation(s)
- Ruben Rodríguez-Mena
- Department of Neurosurgery, Yeditepe University School of Medicine, Kozyatagi Kadikoy, Istanbul, Turkey
| | - Uğur Türe
- Department of Neurosurgery, Yeditepe University School of Medicine, Kozyatagi Kadikoy, Istanbul, Turkey.
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18
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Neuroanatomy: The added value of the Klingler method. Ann Anat 2016; 208:187-193. [DOI: 10.1016/j.aanat.2016.06.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/10/2016] [Accepted: 06/01/2016] [Indexed: 11/24/2022]
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19
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Burks JD, Bonney PA, Conner AK, Glenn CA, Briggs RG, Battiste JD, McCoy T, O'Donoghue DL, Wu DH, Sughrue ME. A method for safely resecting anterior butterfly gliomas: the surgical anatomy of the default mode network and the relevance of its preservation. J Neurosurg 2016; 126:1795-1811. [DOI: 10.3171/2016.5.jns153006] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEGliomas invading the anterior corpus callosum are commonly deemed unresectable due to an unacceptable risk/benefit ratio, including the risk of abulia. In this study, the authors investigated the anatomy of the cingulum and its connectivity within the default mode network (DMN). A technique is described involving awake subcortical mapping with higher attention tasks to preserve the cingulum and reduce the incidence of postoperative abulia for patients with so-called butterfly gliomas.METHODSThe authors reviewed clinical data on all patients undergoing glioma surgery performed by the senior author during a 4-year period at the University of Oklahoma Health Sciences Center. Forty patients were identified who underwent surgery for butterfly gliomas. Each patient was designated as having undergone surgery either with or without the use of awake subcortical mapping and preservation of the cingulum. Data recorded on these patients included the incidence of abulia/akinetic mutism. In the context of the study findings, the authors conducted a detailed anatomical study of the cingulum and its role within the DMN using postmortem fiber tract dissections of 10 cerebral hemispheres and in vivo diffusion tractography of 10 healthy subjects.RESULTSForty patients with butterfly gliomas were treated, 25 (62%) with standard surgical methods and 15 (38%) with awake subcortical mapping and preservation of the cingulum. One patient (1/15, 7%) experienced postoperative abulia following surgery with the cingulum-sparing technique. Greater than 90% resection was achieved in 13/15 (87%) of these patients.CONCLUSIONSThis study presents evidence that anterior butterfly gliomas can be safely removed using a novel, attention-task based, awake brain surgery technique that focuses on preserving the anatomical connectivity of the cingulum and relevant aspects of the cingulate gyrus.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Dee H. Wu
- 4Radiological Sciences, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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20
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Baydin S, Gungor A, Tanriover N, Baran O, Middlebrooks EH, Rhoton AL. Fiber Tracts of the Medial and Inferior Surfaces of the Cerebrum. World Neurosurg 2016; 98:34-49. [PMID: 27184897 DOI: 10.1016/j.wneu.2016.05.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 05/06/2016] [Accepted: 05/07/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Fiber dissection studies of the cerebrum have focused on the lateral surface. No comparable detailed studies have been done on the medial and inferior surfaces. The object of this study was to examine the fiber tracts, cortical, and subcortical structures of the medial and inferior aspects of the brain important in planning operative approaches along the interhemispheric fissure, parafalcine area, and basal surfaces of the cerebrum. METHODS Twenty formalin-fixed human hemispheres (10 brains) were examined by fiber dissection technique under ×6-×40 magnifications. RESULTS The superior longitudinal fasciculus I, cingulum, inferior longitudinal fasciculus, uncinate fasciculus, optic radiations, tapetum, and callosal fibers were dissected step by step from medial to lateral, exposing the nucleus accumbens, subthalamic nucleus, red nucleus, and central midline structures (fornix, stria medullaris, and stria terminalis). Finally, the central core structures were dissected from medial to lateral. CONCLUSIONS Understanding the fiber network underlying the medial and inferior aspects of the brain is important in surgical planning for approaches along the interhemispheric fissure, parafalcine area, and basal surfaces of the cerebrum.
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Affiliation(s)
- Serhat Baydin
- Department of Neurosurgery, University of Florida, College of Medicine, Gainesville, Florida, USA.
| | - Abuzer Gungor
- Department of Neurosurgery, University of Florida, College of Medicine, Gainesville, Florida, USA
| | - Necmettin Tanriover
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Oguz Baran
- Department of Neurosurgery, University of Florida, College of Medicine, Gainesville, Florida, USA
| | - Erik H Middlebrooks
- Department of Radiology, University of Florida, College of Medicine, Gainesville, Florida, USA
| | - Albert L Rhoton
- Department of Neurosurgery, University of Florida, College of Medicine, Gainesville, Florida, USA
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21
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Pascalau R, Aldea CC, Padurean VA, Szabo B. Comparative Study of the Major White Matter Tracts Anatomy in Equine, Feline and Canine Brains by Use of the Fibre Dissection Technique. Anat Histol Embryol 2015; 45:373-85. [PMID: 26394884 DOI: 10.1111/ahe.12208] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 08/21/2015] [Indexed: 01/31/2023]
Abstract
The spatial anatomy of the white matter tracts is a subject of growing interest not only for researchers but also for clinicians. Imagistic methods have some limitations so that they should be confronted with dissection studies. The aim of this paper was to provide a three-dimensional view of the major white matter tracts in equine, feline and canine brains by use of the fibre dissection technique. Twenty cerebral hemispheres (six equine, four feline and 10 canine brains) were prepared according to the Klingler method. Stepwise mediolateral and lateromedial blunt dissections were performed using wooden sticks and spatulas. The lateromedial dissection was followed by the opening of the lateral ventricle. The use of the same multi-stage procedures resulted in a comparable exposure of the major association, projection and commissural fibres and their spatial relation with the lateral ventricle. To conclude, the proposed techniques are reproducible in equine, feline and canine brains and they can be successfully used for teaching, training or research in the field of neurobiology.
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Affiliation(s)
- R Pascalau
- Iuliu Hatieganu University of Medicine and Pharmacy, 8 Babes Street, 400012, Cluj-Napoca, Romania.
| | - C C Aldea
- Iuliu Hatieganu University of Medicine and Pharmacy, 8 Babes Street, 400012, Cluj-Napoca, Romania
| | - V A Padurean
- Iuliu Hatieganu University of Medicine and Pharmacy, 8 Babes Street, 400012, Cluj-Napoca, Romania
| | - B Szabo
- Department of Anatomy and Embryology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Ophthalmology, Emergency County Hospital, Cluj-Napoca, Romania
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22
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Koutsarnakis C, Liakos F, Liouta E, Themistoklis K, Sakas D, Stranjalis G. The cerebral isthmus: fiber tract anatomy, functional significance, and surgical considerations. J Neurosurg 2015; 124:450-62. [PMID: 26361277 DOI: 10.3171/2015.3.jns142680] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The cerebral isthmus is the white matter area located between the periinsular sulcus and the lateral ventricle. Studies demonstrating the fiber tract and topographic anatomy of this entity are lacking in current neurosurgical literature. Hence, the authors' primary aim was to describe the microsurgical white matter anatomy of the cerebral isthmus by using the fiber dissection technique, and they discuss its functional significance. In addition, they sought to investigate its possible surgical utility in approaching lesions located in or adjacent to the lateral ventricle. METHODS This study was divided into 2 parts and included 30 formalin-fixed cerebral hemispheres, 5 of which were injected with colored silicone. In the first part, 15 uncolored specimens underwent the Klinger's procedure and were dissected in a lateromedial direction at the level of the superior, inferior, and anterior isthmuses, and 10 were used for coronal and axial cuts. In the second part, the injected specimens were used to investigate the surgical significance of the superior isthmus in accessing the frontal horn of the lateral ventricle. RESULTS The microsurgical anatomy of the anterior, superior, and inferior cerebral isthmuses was carefully studied and recorded both in terms of topographic and fiber tract anatomy. In addition, the potential role of the proximal part of the superior isthmus as an alternative safe surgical corridor to the anterior part of the lateral ventricle was investigated. CONCLUSIONS Using the fiber dissection technique along with coronal and axial cuts in cadaveric brain specimens remains a cornerstone in the acquisition of thorough anatomical knowledge of narrow white matter areas such as the cerebral isthmus. The surgical significance of the superior isthmus in approaching the frontal horn of the lateral ventricle is stressed, but further studies must be carried out to elucidate its role in ventricular surgery.
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Affiliation(s)
- Christos Koutsarnakis
- Department of Neurosurgery, University of Athens, Evangelismos Hospital;,Microneurosurgery Laboratory, Evangelismos Hospital, Athens, Greece
| | - Faidon Liakos
- Department of Neurosurgery, University of Athens, Evangelismos Hospital;,Microneurosurgery Laboratory, Evangelismos Hospital, Athens, Greece
| | - Evangelia Liouta
- Hellenic Center for Neurosurgical Research "Petros Kokkalis;" and
| | - Konstantinos Themistoklis
- Department of Neurosurgery, University of Athens, Evangelismos Hospital;,Microneurosurgery Laboratory, Evangelismos Hospital, Athens, Greece
| | - Damianos Sakas
- Department of Neurosurgery, University of Athens, Evangelismos Hospital;,Hellenic Center for Neurosurgical Research "Petros Kokkalis;" and
| | - George Stranjalis
- Department of Neurosurgery, University of Athens, Evangelismos Hospital;,Hellenic Center for Neurosurgical Research "Petros Kokkalis;" and.,Microneurosurgery Laboratory, Evangelismos Hospital, Athens, Greece
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Koutsarnakis C, Liakos F, Kalyvas AV, Sakas DE, Stranjalis G. A Laboratory Manual for Stepwise Cerebral White Matter Fiber Dissection. World Neurosurg 2015; 84:483-93. [DOI: 10.1016/j.wneu.2015.04.018] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 04/06/2015] [Accepted: 04/08/2015] [Indexed: 11/29/2022]
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Ito H, Morino M, Niimura M, Takamizawa S, Shimizu Y. Posterior callosotomy using a parietooccipital interhemispheric approach in the semi-prone park-bench position. J Neurosurg 2015; 123:1322-5. [PMID: 26047417 DOI: 10.3171/2014.12.jns141732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A 2-stage corpus callosotomy is accepted as a palliative procedure for patients older than 16 years with, in particular, medically intractable generalized epilepsy and drop attack seizures and is preferable for a lower risk of disconnection syndrome. Although the methods by which a previously performed craniotomy can be reopened for posterior callosotomy have already been reported, posterior corpus callosotomy using a parietooccipital interhemispheric approach with the patient in a semi-prone park-bench position has not been described in the literature. Here, the authors present a surgical technique for posterior callosotomy using a parietooccipital interhemispheric approach with a semi-prone park-bench position as a second surgery. Although this procedure requires an additional skin incision in the parietooccipital region, it makes the 2-stage callosotomy safer and easier to perform because of reduced intracranial adhesion, less bleeding, and an easier approach to the splenium of the corpus callosum.
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Affiliation(s)
- Hirotaka Ito
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Michiharu Morino
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Manabu Niimura
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Sachiko Takamizawa
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Yoshie Shimizu
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
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Goga C, Türe U. The anatomy of Meyer's loop revisited: changing the anatomical paradigm of the temporal loop based on evidence from fiber microdissection. J Neurosurg 2015; 122:1253-62. [DOI: 10.3171/2014.12.jns14281] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The goal in this study was to explore and further refine comprehension of the anatomical features of the temporal loop, known as Meyer's loop.
METHODS
The lateral and inferior aspects of 20 previously frozen, formalin-fixed human brains were dissected under the operating microscope by using fiber microdissection.
RESULTS
A loop of the fibers in the anterior temporal region was clearly demonstrated in all dissections. This temporal loop, or Meyer's loop, is commonly known as the anterior portion of the optic radiation. Fiber microdissection in this study, however, revealed that various projection fibers that emerge from the sublentiform portion of the internal capsule (IC-SL), which are the temporopontine fibers, occipitopontine fibers, and the posterior thalamic peduncle (which includes the optic radiation), participate in this temporal loop and become a part of the sagittal stratum. No individual optic radiation fibers could be differentiated in the temporal loop. The dissections also disclosed that the anterior extension and angulation of the temporal loop vary significantly.
CONCLUSIONS
The fiber microdissection technique provides clear evidence that a loop in the anterior temporal region exists, but that this temporal loop is not formed exclusively by the optic radiation. Various projection fibers of the IC-SL, of which the optic radiation is only one of the several components, display this common course. The inherent limitations of the fiber dissection technique preclude accurate differentiation among individual fibers of the temporal loop, such as the optic radiation fibers.
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Affiliation(s)
- Cristina Goga
- 1Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey; and
- 2Department of Anatomy, University of Medicine and Pharmacy Targu Mures, Romania
| | - Uğur Türe
- 1Department of Neurosurgery, Yeditepe University School of Medicine, Istanbul, Turkey; and
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Zhao X, Shen X, Chen X, Zhang J, Wang X, Zhang Y, Tu Y, Zheng G. Integrated functional neuronavigation-guided resection of small meningiomas of the atrium via the paramedian parieto-occipital approach. Clin Neurol Neurosurg 2014; 128:47-52. [PMID: 25462095 DOI: 10.1016/j.clineuro.2014.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 10/14/2014] [Accepted: 11/04/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Small meningiomas located in the atrium of the lateral ventricle remain a challenge for neurosurgeons due to the eloquent nature of the surrounding anatomy. Functional MRI (fMRI) and diffusion tensor tractography (DTT) allow for in vivo demonstrations of eloquent cortical structures and neuronal fiber tracts, respectively. Our objective is to evaluate the contribution of functional neuronavigation combined with fMRI and DTT results to surgical outcomes. MATERIALS AND METHODS we investigated 11 patients with small meningiomas located in the atrium of the lateral ventricle who underwent surgery with the aid of functional neuronavigation via the paramedian parieto-occipital approach. The patients willingly underwent assessments of neurologic deficits preoperatively and postoperatively at discharge and at three months after surgery. RESULTS Gross total resection was achieved in all patients, and no residual or recurrent tumors were observed on follow-up imaging. There was no mortality. Only one patient suffered from transient postoperative aphasia (mild to moderate) that was resolved one week after surgery. No novel neurologic deficits were present in any of the other patients, and no new-onset epileptic attacks were observed. CONCLUSIONS With the aid of the neuronavigation that incorporates fMRI and DTT results, small meningiomas located in the atrium of the lateral ventricle can be safely resected through the paramedian parieto-occipital approach.
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Affiliation(s)
- Xin Zhao
- Department of Radiology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Xuefeng Shen
- Department of Occupational and Environmental Health and The Ministry of Education Key Laboratory of Hazard Assessment and Control in Special Operational Environment, School of Public Health, The Fourth Military Medical University, Xi'an 710032, China
| | - Xiaolei Chen
- Department of Neurosurgery, PLA General Hospital, Beijing 100853, China
| | - Jiashu Zhang
- Department of Neurosurgery, PLA General Hospital, Beijing 100853, China
| | - Xin Wang
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston 02115, USA
| | - Yuhui Zhang
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston 02115, USA
| | - Yanyang Tu
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston 02115, USA; Department of Experimental Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China.
| | - Gang Zheng
- Department of Neurosurgery, PLA General Hospital, Beijing 100853, China; Department of Neurosurgery, Wulumuqi General Hospital of PLA, Wulumuqi 830000, China.
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Huisman TA, Bosemani T, Poretti A. Diffusion Tensor Imaging for Brain Malformations. Neuroimaging Clin N Am 2014; 24:619-37. [DOI: 10.1016/j.nic.2014.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Alarcon C, de Notaris M, Palma K, Soria G, Weiss A, Kassam A, Prats-Galino A. Anatomic Study of the Central Core of the Cerebrum Correlating 7-T Magnetic Resonance Imaging and Fiber Dissection With the Aid of a Neuronavigation System. Oper Neurosurg (Hagerstown) 2013; 10 Suppl 2:294-304; discussion 304. [DOI: 10.1227/neu.0000000000000271] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Different strategies have been used to study the fiber tract anatomy of the human brain in vivo and ex vivo. Nevertheless, the ideal method to study white matter anatomy has yet to be determined because it should integrate information obtained from multiple sources.
OBJECTIVE:
We developed an anatomic method in cadaveric specimens to study the central core of the cerebrum combining traditional white matter dissection with high-resolution 7-T magnetic resonance imaging (MRI) of the same specimen coregistered using a neuronavigation system.
METHODS:
Ten cerebral hemispheres were prepared using the traditional Klingler technique. Before dissection, a structural ultrahigh magnetic field 7-T MRI study was performed on each hemisphere specifically prepared with surface fiducials for neuronavigation. The dissection was then performed from the medial hemispheric surface using the classic white fiber dissection technique. During each step of the dissection, the correlation between the anatomic findings and the 7-T MRI was evaluated with the neuronavigation system.
RESULTS:
The anatomic study was divided in 2 stages: diencephalic and limbic. The diencephalic stage included epithalamic, thalamic, hypothalamic, and subthalamic components. The limbic stage consisted of extending the dissection to complete the Papez circuit. The detailed information given by the combination of both methods allowed us to identify and validate the position of fibers that may be difficult to appreciate and dissect (ie, the medial forebrain bundle).
CONCLUSION:
The correlation of high-definition 7-T MRI and the white matter dissection technique with neuronavigation significantly improves the understanding of the structural connections in complex areas of the human cerebrum.
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Affiliation(s)
- Carlos Alarcon
- Laboratory of Surgical Neuroanatomy (LSNA), Universitat de Barcelona, Barcelona, Spain
- Department of Neurosurgery, Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Matteo de Notaris
- Laboratory of Surgical Neuroanatomy (LSNA), Universitat de Barcelona, Barcelona, Spain
- Department of Neurosurgery, Hospital Clinic, Barcelona, Spain
| | - Kenneth Palma
- Experimental MRI 7T Unit, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Guadalupe Soria
- Laboratory of Surgical Neuroanatomy (LSNA), Universitat de Barcelona, Barcelona, Spain
- Department of Neurosurgery, University of Pisa, Pisa, Italy
| | - Alessandro Weiss
- Department of Neurosurgery, Division of Neurosurgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Amin Kassam
- Laboratory of Surgical Neuroanatomy (LSNA), Universitat de Barcelona, Barcelona, Spain
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Talacchi A, Hasanbelliu A, Fasano T, Gerosa M. Interhemispheric approach to tumors of the posterior gyrus cinguli. Clin Neurol Neurosurg 2012; 115:597-602. [PMID: 22871382 DOI: 10.1016/j.clineuro.2012.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 07/12/2012] [Accepted: 07/14/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Posterior gyrus cinguli tumors are a well-defined group of tumors that pose considerable challenges in creating surgical access and manipulating adjacent eloquent areas (visual and motor). Here we report our 5-year experience in the surgical treatment of these tumors and describe tumor characteristics, surgical steps, critical aspects, and prognostic factors. METHODS This series comprises 37 patients operated on for glioma (high-grade in 28, low-grade in 9), often presenting with motor impairment (n=20), intracranial hypertension (n=15), seizures (n=11), and/or hemianopia (n=9). Preoperative assessment was performed with magnetic resonance imaging. Half of the tumors were more than 4 cm in size, and the majority presented secondary extension into the fronto-parieto-occipital area, the temporo-mesial area, and/or the corpus callosum. Positioning and assisted surgery were optimized in each patient based on preoperative planning. RESULTS The ipsilateral interhemispheric approach was elected in all cases. Tumor size and extension were significantly associated with the degree of tumor removal. Total removal was achieved in 25 patients (65%); 4 (10%) had persistent morbidity (visual or motor deficits). The occurrence of local and systemic complications was negligible. CONCLUSIONS Surgical treatment of posterior gyrus cinguli tumors can be safely approached via the interhemispheric route as it permits several beneficial operative maneuvers in selected cases.
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Affiliation(s)
- Andrea Talacchi
- Section of Neurosurgery, Department of Neurosciences, University of Verona, Italy.
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Resection of gliomas in the cingulate gyrus: functional outcome and survival. J Neurooncol 2012; 109:341-8. [DOI: 10.1007/s11060-012-0898-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2011] [Accepted: 05/09/2012] [Indexed: 10/28/2022]
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Párraga RG, Ribas GC, Welling LC, Alves RV, de Oliveira E. Microsurgical Anatomy of the Optic Radiation and Related Fibers in 3-Dimensional Images. Oper Neurosurg (Hagerstown) 2012; 71:160-71; discussion 171-2. [DOI: 10.1227/neu.0b013e3182556fde] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
The fiber dissection technique provides unique 3-dimensional anatomic knowledge of the white matter.
OBJECTIVE:
To examine the optic radiation anatomy and its important relationship with the temporal stem and to discuss its findings in relation to the approaches to temporal lobe lesions.
METHODS:
We studied 40 cerebral hemispheres of 20 brains that had been fixed in formalin solution for 40 days. After removal of the arachnoid membrane, the hemispheres were frozen, and the Klingler technique was used for dissection under magnification. Stereoscopic 3-dimensional images of the dissection were obtained for illustration.
RESULTS:
The optic radiations are located deep within the superior and middle temporal gyri, always above the inferior temporal sulcus. The mean distance between the cortical surface and the lateral edge of the optic radiation was 21 mm. Its fibers are divided into 3 bundles after their origin. The mean distance between the anterior tip of the temporal horn and the Meyer loop was 4.5 mm, between the temporal pole and the anterior border of the Meyer loop was 28.4 mm, and between the limen insulae and the Meyer loop was 10.7 mm. The mean distance between the lateral geniculate body and the lateral margin of the central bundle of the optic radiation was 17.4 mm.
CONCLUSION:
The white matter fiber dissection reveals the tridimensional intrinsic architecture of the brain, and its knowledge regarding the temporal lobe is particularly important for the neurosurgeon, mostly because of the complexity of the optic radiation and related fibers.
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Affiliation(s)
- Richard Gonzalo Párraga
- Institute of Neurological Sciences, Microneurosurgery Laboratory, Beneficência Portuguesa Hospital, São Paulo, SP, Brazil
| | - Guilherme Carvalhal Ribas
- Department of Surgery-LIM 02, University of São Paulo Medical School, São Paulo, SP, Brazil
- Microneurosurgery Laboratory, Beneficência Portuguesa Hospital, São Paulo, SP, Brazil
- Institute of Neurological Sciences, Neurosurgeon Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Leonardo Christiaan Welling
- Institute of Neurological Sciences, Microneurosurgery Laboratory, Beneficência Portuguesa Hospital, São Paulo, SP, Brazil
| | - Raphael Vicente Alves
- Institute of Neurological Sciences, Microneurosurgery Laboratory, Beneficência Portuguesa Hospital, São Paulo, SP, Brazil
| | - Evandro de Oliveira
- Institute of Neurological Sciences, Microneurosurgery Laboratory, Beneficência Portuguesa Hospital, São Paulo, SP, Brazil
- Microneurosurgery Laboratory, Beneficência Portuguesa Hospital, São Paulo, SP, Brazil
- Department of Neurosurgery, State University of Campinas-UNICAMP, Campinas, SP, Brazil
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Shah A, Jhawar SS, Goel A. Analysis of the anatomy of the Papez circuit and adjoining limbic system by fiber dissection techniques. J Clin Neurosci 2011; 19:289-98. [PMID: 22209397 DOI: 10.1016/j.jocn.2011.04.039] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 04/20/2011] [Accepted: 04/23/2011] [Indexed: 10/14/2022]
Abstract
Fiber dissection techniques were used to study the limbic system, in particular the Papez circuit. The course, length and anatomical relations of the structures that make up the Papez circuit were delineated. Ten previously frozen and formalin-fixed cadaveric human brains were used, and dissected according to the fiber dissection techniques of Klingler et al. (Schweiz Arch Neurol Psychiatry 1935;36:247-56). The primary dissection tools were thin and curved wooden and metallic spatulas with tips of varying sizes. We found that the Papez circuit (mean length: 350 mm) begins in the hippocampus and continues into the fornix to reach the mamillary body. From there, the mamillothalamic tract continues to the anterior nucleus of the thalamus, which in turn connects to the cingulum by means of anterior thalamic radiations (mean length: 30 mm). The cingulum courses around the corpus callosum to end in the entorhinal cortex, which then projects to the hippocampus, thus completing the circuit. The average length and breadth of the mamillothalamic tract was 18 mm and 1.73 mm respectively. The average length of the cingulum was 19.6 cm and that of the fornix was 71 mm. The entire circuit was anatomically dissected first in situ in the hemisphere and was then reconstructed outside after removing its various components using fine fiber dissection under a surgical microscope. We found that fiber dissection elegantly delineates the anatomical subtleties of the Papez circuit and provides a three-dimensional perspective of the limbic system. Intricate knowledge of the anatomy of this part of the brain aids the neurosurgeon while performing epilepsy surgery and while approaching intrinsic brain parenchymal, ventricular and paraventricular lesions.
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Affiliation(s)
- Abhidha Shah
- Department of Neurosurgery, Seth G.S Medical College and King Edward VII Memorial Hospital, Acharya Donde Marg, Parel, Mumbai 400012, India
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Li Y, Zhao G, Wang H, Zhu W, Qu L, Li Y, Yu J. Use of 3D-computed tomography angiography for planning the surgical removal of pineal region meningiomas using Poppen's approach: a report of ten cases and a literature review. World J Surg Oncol 2011; 9:64. [PMID: 21676231 PMCID: PMC3125353 DOI: 10.1186/1477-7819-9-64] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2011] [Accepted: 06/15/2011] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There are several treatment approaches for pineal region meningiomas, such as Poppen's approach, Krause's approach and combinations of the two approaches. We present our experience with the use of 3D-computed tomography angiography for planning the surgical removal of pineal region meningiomas using a suboccipital transtentorial approach (Poppen's approach) and evaluate the role of Poppen's approach. METHODS During the period from January 2005 to June 2010, ten patients presented to us with pineal region meningioma. MRI was routinely used to define the tumor size, position, and its relevant complications while 3D-CTA was applied to define the blood supply of the tumor and the venous complex (VC) shift before operations. Most of the meningiomas had developed at both sides of the tentorial plane and extended laterally with typical characteristics of a pineal region tumor. RESULTS All tumors were completely removed surgically without any injury to the VC. Postoperative intracranial infection occurred in one case who recovered after antibiotics were given. Postoperative intraventricular hemorrhage and pneumocephalus were found in one case, but fully recovered after conservative treatment. In the nine cases of concurrent hydrocephalus, this was gradually relieved in eight patients and the single case that became aggravated was successfully treated with ventriculoperitoneal shunt. Moreover, the follow-up MRI examinations did not indicate any recurrence of the meningiomas. CONCLUSION We found that the use of Poppen's approach is strongly supported for the successful removal of pineal region meningiomas without serious complications.
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Affiliation(s)
- Yunqian Li
- Department of Neurosurgery, The First Bethune Hospital of Jilin University, 71 Xinmin Avenue, Changchun 130021, China
| | - Gang Zhao
- Department of Neurosurgery, The First Bethune Hospital of Jilin University, 71 Xinmin Avenue, Changchun 130021, China
| | - Honglei Wang
- Department of Neurosurgery, The First Bethune Hospital of Jilin University, 71 Xinmin Avenue, Changchun 130021, China
| | - Wanan Zhu
- Department of Radiology, The First Bethune Hospital of Jilin University, 71 Xinmin Avenue, Changchun 130021, China
| | - Limei Qu
- Department of Pathology, The First Bethune Hospital of Jilin University, 71 Xinmin Avenue, Changchun 130021, China
| | - Ye Li
- Department of Radiology, The First Bethune Hospital of Jilin University, 71 Xinmin Avenue, Changchun 130021, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Bethune Hospital of Jilin University, 71 Xinmin Avenue, Changchun 130021, China
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Kim YB, Young WL, Lawton MT. Parafalcine and midline arteriovenous malformations: surgical strategy, techniques, and outcomes. J Neurosurg 2011; 114:984-93. [DOI: 10.3171/2010.12.jns101297] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Parafalcine arteriovenous malformations (AVMs) have a midline plane in common, but differ in their location (anterior, middle, or posterior) and depth (superficial or deep). Surgical management varies with AVM location and depth in terms of patient position, head position, craniotomy, and surgical approach. This study examined surgical strategies, patient outcomes, and regional factors influencing results.
Methods
Patients with AVMs located on the medial surface of the cerebral hemisphere were identified retrospectively from a consecutive, single-neurosurgeon series that is registered prospectively as part of the UCSF Brain Arteriovenous Malformation Study Project. During a 12-year period, 443 patients with AVMs were treated surgically. Of these 443 patients, 132 (30%) had parafalcine AVMs, which were distributed in zones as follows: superficial-anterior, 25 (18.9%); superficial-middle, 26 (19.7%); superficial-posterior, 39 (29.5%); deep-anterior, 25 (18.9%); deep-posterior, 17 (12.9%). Five different surgical strategies were used depending on AVM zone.
Results
Complete AVM resection was achieved in 123 (93.2%) of 132 patients. Overall, neurological condition improved in 74 patients (56.1%) and remained unchanged in 41 patients (31.1%). Neurological condition deteriorated in 12 patients (9.1%), and 5 patients (3.8%) died. Patients with AVMs in the superficial-middle zone had the highest rate of neurological deterioration (26.9%).
Conclusions
Parafalcine AVMs lie on a midline surface that, when exposed with a bilateral craniotomy across the superior sagittal sinus and a wide opening of the interhemispheric fissure, makes them superficial. However, unlike convexity AVMs, which are approached perpendicularly, parafalcine AVMs are approached tangentially. Gravity retraction is useful with deeply located AVMs (those in the deep-anterior and deep-posterior zones), because it widens the interhemispheric fissure and accesses deep arterial feeding vessels from the anterior and posterior cerebral arteries. Surgical risks were increased in the superficial-middle zone, which is likely explained by the proximity of sensorimotor cortex. The authors' regional classification of parafalcine AVMs may serve as a guide to surgical planning.
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Affiliation(s)
| | - William L. Young
- 1Departments of Neurological Surgery,
- 2Anesthesia and Perioperative Care, and
- 3Neurology, and
- 4Center for Cerebrovascular Research, University of California, San Francisco, California
| | - Michael T. Lawton
- 1Departments of Neurological Surgery,
- 4Center for Cerebrovascular Research, University of California, San Francisco, California
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Talacchi A, Corsini F, Gerosa M. Surgical approaches to tumors of the anterior gyrus cinguli. Neurosurgery 2010; 66:245-51. [PMID: 20489513 DOI: 10.1227/01.neu.0000369652.59204.99] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tumors of the gyrus cinguli are deep-seated, and may require a variety of surgical options. We focused on anterior tumors, which have specific anatomic and surgical features. OBJECTIVE To evaluate different approaches and indications through detailed description and a review of our experience. METHODS These approaches include unilateral interhemispheric or combined: bilateral interhemispheric, unilateral plus superior frontal gyrectomy, or unilateral plus frontal polectomy. The relevance of this retrospective analysis is stressed by the extremely limited literature in this regard. RESULTS In the past 5 years we operated on 38 patients with gliomas. We compared the following variables: location (perigenual, prerolandic), pathology (glioblastoma, other gliomas), size (<4 cm, > or =4 cm), extension (unilateral, bilateral), and approach (unilateral interhemispheric, combined). The only significant association we found was between tumor location (perigenual) and bilateral extension (P < .01). However, combined approaches were adopted only slightly more frequently in this region than in the prerolandic area, and this resulted in a lower rate of total removal (33% vs 76%, P < .01). Gross total removal was achieved in 28 cases (66%) and was significantly associated with combined approaches (77% vs 50%, P < .05). CONCLUSIONS The choice of a combined approach to anterior gyrus cinguli tumors is critical to improving the quality of resection in selected cases. We recommend a combined approach in the surgical treatment of large tumors of the perigenual area.
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Affiliation(s)
- Andrea Talacchi
- Section of Neurosurgery, Department of Neurological Sciences and Vision, University of Verona, Verona, Italy.
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Wang S, Salma A, Ammirati M. Posterior interhemispheric transfalx transprecuneus approach to the atrium of the lateral ventricle: a cadaveric study. J Neurosurg 2010; 113:949-54. [PMID: 20151777 DOI: 10.3171/2010.1.jns091169] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The posterior interhemispheric transprecuneus gyrus approach is one of the surgical routes that has been suggested to reach the atrium of the lateral ventricle. It has the advantage of avoiding the disruption of the optic radiations; however, it has a narrow working area that at times makes the execution of this approach rather challenging. The aim of this study was to test a modification of the approach that might create a better surgical angle and a wider corridor by accessing the atrium from the contralateral side after transection of the falx. The authors named this new approach the "posterior interhemispheric transfalx transprecuneus approach." METHODS The posterior interhemispheic transfalx transprecuneus approach was performed bilaterally on 6 fresh adult cadaveric specimens for a total of 12 procedures. Every head was held in the semisitting position and a parasagittal parietooccipital craniotomy on the contralateral side of the targeted ventricle was executed. The dura mater was opened and reflected based on the sagittal sinus. Then the falx was cut in a triangular fashion based on the inferior sagittal sinus. Using the parietooccipital artery and sulcus as landmarks, the contralateral precuneus gyrus was indentified, and a small area of the gyrus was transected to gain access to the atrium. A neuronavigational system was also used to conduct this approach. The working angle of this approach and other distances were measured. RESULTS The authors were able to visualize the ventricular atrium, posterior part of the temporal horn, pulvinar, and choroid plexus in all specimens. The temporal horn could be exposed for a length of 20-30 mm from the atrium. The working angle of the approach was better than that of the classic posterior interhemispheric transprecuneus approach with a mean value of 44.5° as opposed to 25.8°. The distance from the middle point of the corticotomy to the splenium ranged from 11 to 16 mm (mean 13.3 mm); the distance to the torcula, from 34 to 53 mm (mean 41.3 mm); and the distance to the atrium, from 22 to 31 mm (mean 25.7 mm). CONCLUSIONS Results of this study suggested that the proposed approach can expose the atrium and the posterior part of the temporal horn of the lateral ventricle with a wider surgical angle compared with the conventional homolateral posterior interhemispheric transprecuneus gyrus approach. Moreover, by minimizing the amount of brain retraction homolateral to the target, this approach could make navigation more accurate.
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Affiliation(s)
- Song Wang
- Dardinger Microneurosurgical Skull Base Laboratory, Department of Neurological Surgery, The Ohio State University Medical Center, Columbus, Ohio 43210, USA
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Kendir S, Acar HI, Comert A, Ozdemir M, Kahilogullari G, Elhan A, Ugur HC. Window anatomy for neurosurgical approaches. Laboratory investigation. J Neurosurg 2009; 111:365-70. [PMID: 19361260 DOI: 10.3171/2008.10.jns08159] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Knowledge of the cranium projections of the gyral structures is essential to reduce the surgical complications and to perform minimally invasive interventions in daily neurosurgical practice. Thus, in this study the authors aimed to provide detailed information on cranial projections of the eloquent cortical areas. METHODS Ten formalin-fixed adult human skulls were obtained. Using sutures and craniometrical points, the crania were divided into 8 windows: superior frontal, inferior frontal, superior parietal, inferior parietal, sphenoidal, temporal, superior occipital, and inferior occipital. The projections of the precentral gyrus, postcentral gyrus, inferior frontal gyrus, superior temporal gyrus, transverse temporal gyri, Heschl gyrus, genu and splenium of the corpus callosum, supramarginal gyrus, angular gyrus, calcarine sulcus, and sylvian fissure to cranial vault were evaluated. RESULTS Three-fourths of the precentral gyrus and postcentral gyrus were in the superior parietal window. The inferior frontal gyrus extended to the inferior parietal window in 80%. The 3 important parts of this gyrus were located below the superior temporal line in all hemispheres. The orbital and triangular parts were in the inferior frontal window, and the opercular part was in the inferior parietal window. The superior temporal gyrus was usually located in the inferior parietal and temporal windows, whereas the supramarginal gyrus and angular gyrus were usually located in the superior and inferior parietal windows. The farthest anterior point of the Heschl gyrus was usually located in the inferior parietal window. The mean positions of arachnoid granulations were measured as 3.9 +/- 0.39 cm anterior and 7.3 +/- 0.51 cm posterior to the bregma. CONCLUSIONS Given that recognition of the gyral patterns underlying the craniotomies is not always easy, awareness of the coordinates and projections of certain gyri according to the craniometric points may considerably contribute to surgical interventions.
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Affiliation(s)
- Simel Kendir
- Department of Anatomy, Ankara University, Sihhiye, Ankara, Turkey
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Mahaney KB, Abdulrauf SI. Anatomic relationship of the optic radiations to the atrium of the lateral ventricle: description of a novel entry point to the trigone. Neurosurgery 2008; 63:195-202; discussion 202-3. [PMID: 18981826 DOI: 10.1227/01.neu.0000313121.58694.4a] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of this study was to delineate the anatomic relationship of the optic radiations to the atrium of the lateral ventricle using the Klingler method of white matter fiber dissection. These findings were applied to define a surgical approach to the trigone that avoids injury to the optic radiations. METHODS Sixteen cadaveric hemispheres were prepared by several cycles of freezing and thawing. With the use of wooden spatulas, the specimens were dissected in a stepwise fashion. Each hemisphere was dissected first from a lateromedial direction and then from a mediolateral approach, and careful attention was given to the course and direction of the optic radiation fibers at all points from Meyer's loop to their termination at the cuneus and the lingual gyrus. RESULTS In all 16 dissected hemispheres, the following observations were made: 1) the entire lateral wall of the lateral ventricle-from the temporal horn to the trigone to the occipital horn-is covered by the optic radiations; and 2) the medial wall of the lateral ventricle in the area of the trigone is entirely free of the optic radiations. CONCLUSION The results of this study confirm that the medial parieto-occipital interhemispheric approach to the ventricular trigone will avoid injury to the optic radiations and the calcarine cortex. The authors describe the most direct trajectory to the ventricular trigone using this approach and propose a point of entry that transects the cingulate gyrus at a point 5 mm superior and 5 mm posterior to the falcotentorial junction.
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Affiliation(s)
- Kelly B Mahaney
- Saint Louis University Center for Cerebrovascular and Skull Base Surgery, St. Louis, Missouri, USA
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Rivet DJ, Moran CJ, Mazumdar A, Pilgram TK, Derdeyn CP, Cross DT. Single-institution experience with matrix coils in the treatment of intracranial aneurysms: comparison with same-center outcomes with the use of platinum coils. AJNR Am J Neuroradiol 2007; 28:1736-42. [PMID: 17885252 PMCID: PMC8134208 DOI: 10.3174/ajnr.a0633] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE This study was undertaken to analyze the outcomes and treatment-related complications of the polyglycolic/polylactic acid (PGLA)-coated Matrix platinum coils in the treatment of intracranial aneurysms and compare these results with those derived from the same single-institutional experience with use of uncoated, bare platinum coils. MATERIALS AND METHODS In this study, we compared 2 groups of patients in a retrospective fashion. The first group consisted of 70 consecutive patients who underwent 82 aneurysm treatments with Matrix coils during the 14-month period of study, from January 2003 to February 2004. We compared this cohort with 70 consecutive patients who underwent a total of 80 aneurysm treatments with bare platinum coils in the 12 months immediately preceding the use of PGLA-coated coils, from January through December 2002. We then recorded the treatment characteristics, angiographic outcomes, and any complications. RESULTS There were similar baseline demographic characteristics between the 2 study groups except in age, anatomic location, and length of follow-up. The overall recurrence rate of aneurysms was 41% among the Matrix-treated group and 32% among the patients treated with bare platinum. Among the 42 patients treated with 100% Matrix, the rate of recurrence was 31%. Of the recurrences, 21% of the Matrix group, 19% of the 100% Matrix group, and 9% of the bare platinum group required retreatment. The overall rate of complications was 10% in the Matrix-treated group and 7% in the bare platinum group. There was not a statistically significant difference in the rate of recurrence of aneurysms or complications between the 2 groups. CONCLUSIONS On the basis of our single-center experience, there is insufficient evidence to support the use of Matrix coils over bare platinum coils, given their disadvantages.
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Affiliation(s)
- D J Rivet
- Neuroradiology Section, Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, MO, USA.
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